Tip: Have clear documentation when sepsis or SIRS is POA

 

Never assume that sepsis is present on admission (POA). Sepsis or severe sepsis may be present on admission but the physician may not confirm the diagnosis until sometime after admission. When physician documentation stating that sepsis or severe sepsis is POA is absent or unclear, coders should query the physician. Similarly, coders should never assume that the presence of SIRS criteria on admission allows the coder to report ICD-9-CM code 038.x as the principal code without corroborating physician documentation that verifies sepsis was POA.

 

This is especially important from a compliance standpoint as RACs found more than $300 million in potential revenue their first year in existence.

 

Editor’s note: This tip was excerpted from the February 5 HCPro audio conference “Sepsis Documentation and Coding: Clinical Indications, ICD-9 Guidelines, and Queries for Clarity.” To listen to the audio conference, visit www.hcmarketplace.com/prod-7461.html.