This Coding Tip was updated on 8/12/2022
In 2018, HIA reviewed 39,828 inpatient records. This is part 2 of a series as we look at the top 5 DRG’s with recommendations over this week.
#2 DRG with the most recommendations
DRG 872—Septicemia w/o MV 96+ hours without MCC
For this DRG there were several different DRG’s that were recommended.
The majority of the recommendations from DRG 872 (Septicemia w/o mechanical ventilation 96+ hours w/o MCC) were to DRG 871 (Septicemia w/o mechanical ventilation 96+ hours with MCC) with the addition of an MCC to the account. Not all of these required a physician query and were present in the medical record documentation without any clarification needed prior to coding.
- Review the entire medical record to ensure that all diagnoses that meet reporting guidelines have been coded to the highest degree of specificity documented. If the record is coded completely from the start of coding this will save time going back into the record searching for a possibly missed documented MCC.
- Query if needed to confirm/clarify a documented possible MCC when it is not clearly documented within the record.
The second most common DRG recommended was 698 (other kidney & urinary tract diagnoses with MCC) with the re-sequencing of the urinary infection as the PDX. Not all of these in this DRG required a physician query as the documentation found in the record by the reviewer ruled out the diagnosis of sepsis, or the determination of sepsis being present on admission or not.
- Verify that the diagnosis of sepsis is clearly documented and supported before reporting as the PDX. If there is any question at all on this diagnosis, a query should be sent.
- Reasons for queries before reporting sepsis as the PDX may be to clarify if the diagnosis was present on admission or if this was ruled out. Oftentimes coders will see documentation of sepsis after admission. Even if the clinical indicators are present at the time of admission, if the diagnosis is not made until later in the stay a query is needed.
- Another common documentation issue that coders see is sepsis and bacteremia being used in the medical record interchangeably and then the discharge summary is completed with only bacteremia. Coders should obtain further clarification from the physician to determine if sepsis was ruled out and the patient only has bacteremia or if sepsis was present for this patient.
Several recommendations were made within DRG 872 where a procedure was found to be performed but not coded, patient was on mechanical ventilation over 96 hours, or that sepsis was due to or possibly due to urinary/vascular/other device/catheter. Some of these did require physician query to clarify but others were clearly documented in the medical record.
- Coders should review the entire medial record to look for procedures that were performed. There may not be a formal operative note in the record however, the orders and progress notes should give the coder a clue to look further or query the physician.
- Review the medical record to verify if the patient was placed on mechanical ventilation and if so for how long.
- When the patient has documentation of a urinary/vascular/other device/catheter review the medical record to see if the physician has documented that this is the cause for the patient’s sepsis. Depending on documentation, it may be that a physician query is needed for clarification.
Be on the lookout for Part 3 of this series.
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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