Query Tip: Is Sepsis Present on Admission?

What should a coder do in this scenario? Patient is admitted with pneumonia and has clinical indicators of hypotension (BP 90/55), tachycardia (HR 125), fever (101.0), and elevated white count (16.5). The physician documents sepsis for the first time on day 3. The coder should not assume sepsis was present on admission (POA) without a query to the physician.

The query must include any relevant indicators from the time of admission, as well as the documented diagnosis of sepsis. Below are some of the most common clinical indicators to look for (Sepsis-2 criteria):

• Fever (>100.4 F (38.6 C) or hypothermia <96.8 F (36 C) Tachypnea (>20 breaths per minute or PaCO2 < 32 mg/mercury)
• Tachycardia (heart rate >90 BPM)
• Leukocytosis or leukopenia (>12,000 or <4,000 or normal with > 10% bands)
• Hypotension
• Organ failure/dysfunction
• Elevated lactic acid (> 1.5 times normal) or anion gap (>/= 15 or based on reference lab values)
• Altered mental status
• Shock
• Positive blood culture

In addition to positive clinical indicators documented at the time of admission, any of these that occur within the few days after admission should also be included. This will support the fact that sepsis could have developed after admission. It is important that a POA query give equal attention to what supports POA yes, as well as POA no to avoid the appearance of a leading query. For example, in the previous scenario, if the patient did not become hypotensive until day 3 when sepsis was first documented, this may indicate that sepsis developed after admission, despite several clinical indicators being present at the time of admission.

Here is a sample query for POA status of sepsis. Present on admission status is one of the specific instances where Yes/No query format is permitted. AHIMA Practice Brief 2016