Physician Query for Sepsis vs. SIRS
A 72-year-old male is admitted with fever (102.3°F), tachycardia (118 bpm), tachypnea (24 breaths/min), and leukocytosis (15,000/mm³). Blood cultures are drawn, and the patient is started on IV antibiotics within 3 hours. The discharge summary states: 'Sepsis due to urinary tract infection, resolved. UTI treated.' The urine culture grows E. coli. The physician documented 'sepsis' in the admission note but later wrote 'bacteremia' in the discharge summary. The coding professional reviews the record and finds no other documentation of sepsis. The facility's query policy allows verbal queries but requires them to be documented in the health record. The physician is known to prefer not to be queried after discharge.
1. Should the coder query the physician? Justify your answer using ICD-10-CM Official Guidelines and compliance standards.
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Yes, a query is warranted. The documentation is conflicting: 'sepsis' in the admission note versus 'bacteremia' in the discharge summary. Sepsis requires a causal organism and organ dysfunction (per Sepsis-3 criteria, though ICD-10-CM coding does not strictly require Sepsis-3, it requires physician diagnosis of sepsis). Bacteremia alone does not equal sepsis. The coder cannot assume sepsis based on clinical indicators. The ICD-10-CM Official Guidelines for Coding and Reporting (Section I.B.14) allow queries when documentation is ambiguous or conflicting. A query clarifies the diagnosis and ensures accurate code assignment (A41.9 vs. R78.81). Without a query, assigning sepsis would be unsupported and could be considered upcoding. The query should be concise, include clinical indicators, and offer multiple-choice options (e.g., sepsis, bacteremia, UTI, other).
2. If the physician does not respond to the query, how should the coder proceed? What code(s) should be assigned?
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If the physician does not respond, the coder must assign codes based on the available documentation. The discharge summary is the final summary and states 'bacteremia' and 'UTI treated.' Therefore, assign codes for UTI (N39.0) and bacteremia (R78.81) if documented. Do not assign sepsis (A41.9) because it is not consistently documented. The coder should document the query attempt in the health record per policy. If the facility policy allows, escalate to the physician advisor or clinical documentation improvement team. The coder should not assign a code for sepsis based on clinical indicators alone without physician documentation.