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August 02, 2024 · Revenue Cycle · Health Data

Managing Postoperative Sepsis Poses CDI

and Coding Challenges
By Alba Kuqi MD, MSHIM

Postoperative sepsis remains a significant healthcare challenge, complicating approximately

one to two percent of all surgical procedures and significantly impacting morbidity and
mortality.

The complexity of diagnosing and managing postoperative sepsis is compounded by CDI

and coding challenges, which are crucial for accurate reporting and management of this
condition. Innovations in predictive biomarkers, effective monitoring strategies, and
advancements in treatment protocols are critical to enhance the management of
postoperative sepsis.

Evolving Diagnostic Criteria and Predictive Biomarkers

Accurate diagnosis of sepsis has transitioned from the traditional Systemic Inflammatory
Response Syndrome (SIRS) criteria to a focus on organ dysfunction, reflecting the severity
and urgency of the condition. Model-based insulin sensitivity shows promise as a
biomarker in critical care, offering potential for early detection and improved outcomes in
sepsis management.

Technological advances have significantly improved the monitoring of physiological

parameters in postoperative sepsis. One study demonstrated the potential of myocardial
strain and cardiac output measurements to predict mortality in septic patients, suggesting
their utility in monitoring and therapeutic assessment.

Guidelines from the Surviving Sepsis Campaign recommend specific therapies and
interventions, such as timely antibiotic administration and appropriate fluid resuscitation.
Additionally, a 2020 study explored the prognostic value of presepsin, a biomarker that
can guide therapy choices in septic patients, highlighting its role in predicting sepsis
severity and guiding treatment decisions.

CDI and Coding Challenges

The accuracy of medical coding in sepsis cases directly influences patient outcomes,
healthcare reporting, and hospital reimbursement. Coding errors or inconsistencies can
lead to misreporting of sepsis incidence and severity, potentially affecting the quality of
care.

Effective CDI practices ensure that the clinical nuances of sepsis are accurately captured
and documented, aligning the recorded data with patient care and administrative needs.

CDI programs are vital in bridging the gap between the clinical care a patient receives and
the documentation that reflects this care in the medical record. Accurate documentation is
crucial for coding and billing processes, which in turn ensure appropriate reimbursement
and compliance with healthcare regulations. In the context of postoperative sepsis, the
challenges of CDI and coding are particularly pronounced due to the complexity and
urgency of the condition.

Challenges in Sepsis Documentation and Coding

Here are the main challenges posed by sepsis documentation and coding, which encompass
the evolving clinical definitions, the intricacies of accurately capturing the condition's
severity, and the necessity for continuous education and adaptation among healthcare
professionals:

1. Complexity of Sepsis Definitions: Sepsis is defined by a combination of clinical

criteria and biomarkers indicative of an infection-induced systemic response.
 Changes in the definitions of sepsis, most notably the shift from SIRS criteria to
Sepsis-3, which emphasizes organ dysfunction, have added layers of complexity to
documenting and coding for sepsis. These evolving definitions require constant
updates in training for both CDI specialists and coders.

2. Identification and Documentation: Accurately identifying and documenting sepsis

involves detailed chart reviews and interactions with healthcare providers. The
clinical indicators of sepsis such as elevated heart rate, fever, increased white blood
cell count, or decreased urine output must be documented explicitly alongside a
confirmed or suspected infection source. This nuanced documentation is essential
for coders to apply the correct ICD-10-CM codes.

3. Risk Factor Documentation: Postoperative patients often have multiple risk factors
for sepsis, such as age, underlying chronic conditions, and the nature of the surgical
procedure. Documenting these risk factors is crucial because they influence the
management strategies and coding, especially in cases where risk adjustment is
necessary.

4. Coding Specificity: The ICD-10-CM coding system requires specificity, and the codes
for sepsis are numerous and detailed. For example, coding must distinguish among
sepsis, severe sepsis, and septic shock — each of which has different coding
implications and reimbursement consequences. The specificity required can lead to
coding errors if the documentation is not clear or detailed enough.

5. Timeliness of Documentation: In the fast-paced environment of acute care, timely

documentation is a challenge. Delays in documenting can lead to delays in coding
and billing, which may affect hospital revenue cycles. Moreover, timely and accurate
documentation affects clinical decision-making and patient outcomes in critical care
scenarios.

6. Education and Training: Ongoing education and training for CDI staff, coders, and
healthcare providers are necessary to keep up with changes in sepsis definitions,
coding guidelines, and best practices in documentation. This is particularly
challenging in environments where resources are limited or staff turnover is high.

Strategies to Overcome CDI and Coding Issues

To effectively address and overcome CDI and coding issues, consider implementing the
following strategies:

• Enhanced CDI Programs: Implementing robust CDI programs that actively engage
clinical staff can help improve the accuracy and completeness of documentation.
These programs should include regular training sessions and feedback loops among
CDI specialists, coders, and clinicians.
 • Use of Technology: Advanced software and electronic health record (EHR) systems
can be leveraged to prompt clinicians for specific information needed for accurate
documentation of sepsis. Natural language processing and other artificial intelligence
(AI) tools can aid in identifying potential cases of sepsis from the clinical data.
• Interdisciplinary Collaboration: Regular meetings with clinical teams, CDI
specialists, and coders can help clarify documentation requirements and resolve
ambiguities. Such collaboration ensures that everyone understands the clinical and
coding perspectives.
• Quality Audits: Conducting regular audits of sepsis cases can help identify common
documentation and coding errors, which can then be addressed through targeted
training and process improvement.
• Provider Engagement: Engaging providers through education about the impact of
accurate documentation on patient care and hospital metrics can motivate them to
provide the necessary details in their clinical documentation.

Case Scenario: Demonstrating CDI and Coding in Practice

A 62-year-old patient underwent abdominal surgery and developed signs of infection post-
operation. The patient’s temperature rose to 38.7°C, with a heart rate of 115 bpm and a
white blood cell count of 12,000/µL. Despite these signs, the initial provider's
documentation did not reflect sepsis. As such, the CDI specialist decided to intervene and
place a query asking the provider if the patient presented with sepsis on admission.

Coding Query Example Based on the Case Scenario

To illustrate the practical application of CDI and coding for sepsis patients, the following is
an example of a coding query based on the case scenario described above.

Subject: Request for Clarification on Documentation for Sepsis Coding

Dear Dr. Smith,

I am conducting a review of the patient chart for the individual who underwent abdominal
surgery last week. The patient exhibited a temperature of 38.7°C, a heart rate of 115 bpm, and
an elevated white blood cell count of 12,000/µL.

To ensure comprehensive and accurate documentation, which can significantly impact patient
care management and appropriate resource allocation, please review the details provided below
and clarify the appropriate diagnosis:

**Clinical Indicators**
- Elevated body temperature 38.7°C

- Increased heart rate 115bpm

- Elevated white blood cell count 12,000/uL

**Risk Factors**

- Recent abdominal surgery

- Advanced age

- History of diabetes (if applicable)

**Treatment Administered**

- Administration of broad-spectrum antibiotics

Based on the above information, please indicate whether the following conditions were
considered and/or diagnosed:

Sepsis is an expected occurrence and is not a complication

Sepsis is not an expected occurrence and not a complication

Sepsis is a complication but not due to the recent abdominal surgery -please specify cause:
___________

Sepsis is a complication of the recent abdominal surgery

Patient did not present with sepsis on admission

Other (specify)________________________________

Please provide any additional comments or observations that might assist in accurately
documenting and coding this case. Your response is crucial for ensuring that the severity of the
patient's condition is correctly reflected in our records, which is essential for both clinical
outcomes and compliance with health reporting standards.

Thank you for your collaboration.

Sincerely,
[Your Name]

CDI Specialist

Conclusion
The challenges associated with CDI and coding in the management of postoperative sepsis
are significant, but can be managed through strategic initiatives aimed at improving
documentation accuracy, coder and clinician education, and the use of technology. By
focusing on these areas, healthcare institutions can enhance the quality of care for sepsis
patients and ensure accurate reporting and reimbursement for the services provided.

Managing postoperative sepsis effectively requires a multifaceted approach that includes

the adoption of advanced diagnostic tools, enhanced monitoring strategies, and rigorous
CDI and coding practices. Innovations in these areas are crucial for improving patient
outcomes and adapting to the evolving healthcare landscape. As research progresses and
new technologies emerge, the integration of these elements into clinical practice will
continue to play a vital role in advancing sepsis management.

Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP, is a candidate
pursuing a Doctor of Public Health degree at Georgia Southern University in Statesboro, GA, with
a passion for advancing public health initiatives and making a meaningful impact on
communities.

 Clinical Documentation Integrity, Revenue Cycle, ICD-10-CM, Medical Coding, EHR

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