query guidelines for cases where the documentation does not
meet clinical criteria established in the medical staff policies
and provider clarification is needed to confirm the diagnosis
and not to just omit the code. This policy should also include
a mechanism for physician involvement in defending sepsis if
contested in an audit in these cases.
Coding and Sepsis
The goal for coding is to have a policy that supports consistent
and accurate reporting of sepsis for reimbursement and internal and external data reporting. As the cooperating parties have
not yet developed new guidelines for this new criteria, organizations will need to be proactive and develop their own policies.
While individual coding professionals should not report codes
solely on the basis of clinical criteria, facilities can and should
adopt/revise internal coding policies that incorporate clinical
information on how to consistently and compliantly code sepsis
and septic shock based on the medical staff’s clinical policy.
Collaboration between the medical, CDI, and coding staff
is a critical success factor in bridging the gap bet ween coding
guidelines and clinical guidelines as well as managing any
claims denials. Furthermore, alignment in CDI and coding
policies and procedures is a key step to successfully mitigating and defending coding and/or clinical denials.
Continued Alignment of Coding and Clinical Guidelines
The strategies and approach described in this article for aligning sepsis coding guidelines and sepsis clinical guidelines can
also be employed for other common diseases and illnesses
where clinical criteria have been defined. Effective claims denial management should help spotlight other areas where collaboration and coordination of clinical and coding policies are
1. Centers for Disease Control and Prevention. ICD-10-CM
Official Guidelines for Coding and Reporting FY 2017.
2. Singer, Mervyn et al. “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis- 3).”
Journal of the American Medical Association 315, no. 8
(February 23, 2016): 801-810. https://jamanetwork.com/
3. Vincent, J. L. et al. “The SOFA (Sepsis-related Organ
Failure Assessment) score to describe organ dysfunc-tion/failure: On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive
Care Medicine.” Intensive Care Medicine 22, no. 7 (July
1996): 707-710. http://icmjournal.esicm.org/Journals/
Natalie Sartori ( firstname.lastname@example.org) is corporate trainer at United Audit Solutions, Inc.
Table 2: SOFA Score
Cardiovascular Abbreviation Key:
Dop = Dopamine Dob = Dobutamine Epi = Epinephrine MAP = Mean Arterial pressure Nor = Norepinephrine
Respiratory CNS Cardiovascular Liver Coagulation Renal
Platelets×103/µL Creatinine mg/
dL(μmol/L) or urine
1 <400 13–14 MAP <70 mmHg 1. 2–1. 9 [ 20-32] <150 1. 2–1. 9
2 <300 10–12 Dop < 5 or Dob (any
2.0– 5. 9 [33-101] <100 2.0– 3. 4
3 <200 and mech.
6–9 Dop 5. 1 - 15 OR Epi
≤0.1 OR Nor ≤0.1
6.0– 11. 9 [102-204] < 50 3. 5–4. 9
or [<500 mL/d]
4 <100 and mech.
< 6 Dop > 15 OR Epi
>0.1 OR Nor >0.1
> 12.0  < 20 > 5.0
or [<200 mL/d]
Quiz ID: Q1838901 | EXPIRATION DATE: JANUAR Y 1, 2019
HIM Domain Area: Clinical Data Management
Article—“Bridging the Gap Between Coding Guidelines and Sepsis
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