Infection for Determination of Severe Sepsis

Identifying infections for the purpose of determining severe sepsis presents a variety of challenges. Whether you are a novice with abstracting severe sepsis case or have been doing it for several months, here are some guidelines: DO NOT USE: Terms on an X-ray that would have been used when abstracting an “abnormal x-ray” for a pneumonia core measure chart – such as infiltrates. Viral or fungal…

Posted on Sep. 8, 2016 in How Should I Code This?

Presentation Time

Recently cases with documentation of severe sepsis/septic shock “present on arrival”; “present on admission” have been generating questions on the correct way to abstract presentation time. Consider these scenarios: Patient arrives to the emergency room on 12/9/15 at 1503. The clinical indicators for severe sepsis are found with the last piece suggesting a presentation date/time of 12/9/15 at 1647. In the H&P the physician documents “Patient…

Posted on Sep. 2, 2016 in How Should I Code This?

Using Lab Values as Organ Failure

One of the common errors when determining severe sepsis presentation occurs when a lab value is used as the last of the indicators. Remember, when using a lab value to determine the presentation time for severe sepsis, you must use the RESULT time, not the collection or order time. The other challenge related to lab results is the question of chronic conditions. In the current data…

Posted on Aug. 24, 2016 in How Should I Code This?

Bone Marrow Transplant Treatment

Bone marrow transplantation (BMT) and peripheral blood stem cell transplantation (PBSCT) are procedures that restore stem cells that have been destroyed by high doses of chemotherapy and/or radiation therapy. If bone marrow is infused, code either 11 or 12 (depends on the source of bone marrow, from patient is autologous or from donor is allogeneic) If peripheral blood stem cells are harvested and infused, code 20…

Posted on Aug. 5, 2016 in How Should I Code This?