Since CMS doesn't recognize AMS as organ dysfunction, if there were no other organ dysfunction criterion, then I would exclude the case as well. The guidelines are looking for severe sepsis. If the pt didn't have any organ dysfunction as listed by CMS, or documentation of severe sepsis/septic shock by a physician/PA/NP, then according to their definition it's not severe sepsis. And this is in the guidelines regarding discharge note:
Disregard any documentation of SIRS criteria, organ dysfunction, an infection, severe sepsis, or septic shock in a discharge note, discharge summary, or documented after the time of discharge. [Logo, company name Description automatically generated]<http://mainlinehealth.org/beseen> KAREN BELFI, RN, MSN Pronouns: she, her Quality Outcomes Coordinator Lankenau Medical Center 100 E. Lancaster Avenue Wynnewood, PA 19094 215-805-2594 cell | [email protected] [cid:[email protected]]<http://mainlinehealth.org/beseen> From: Sepsisgroups <[email protected]> On Behalf Of Cooke, Susan Sent: Wednesday, February 03, 2021 11:41 AM To: [email protected] Subject: [EXTERNAL] [Sepsis Groups] I need some clarification and would appreciate some input This message originated from outside MLHS systems. Any attachments or links should be carefully considered before proceeding. Messages from our business partners still need to be reviewed and should not be opened if suspicious. Please use the report phishing button to report a questionable email. ________________________________ Hi everybody, I am going round and round with our Abstracting company related to a UTI sepsis case. Patient came to ED meeting SIRS criteria and a change in mental status which was reported as definitely improved after antibiotic administration. The Bundle elements were met. The coding was for Sepsis and UTI with a primary of Altered Mental Status. All were POA. The Abstractors excluded the case because they say the patient did have evidence of organ dysfunction because CMS does not recognize Altered Mental Status as Organ dysfunction (but SCCM does). 1. Is this correct that the case should be excluded even though the patient clearly had sepsis. Improved with antibiotics and it was coded as such by the physician? 2. In my email to the Abstractor I had mentioned (because I'm somewhat new to this level of detail and didn't realize the altered mental status wasn't an organ dysfunction) that it was clearly stated in the Discharge Summary that the patient had Altered Mental Status that improved with Antibiotics and the source was a UTI. I was told that -Also,any documentation in the discharge summary is not to be used to determine the presence of severe sepsis/septic shock. Is this true? Isn't the entire chart a possible source for a sepsis diagnosis? Any insight to this type of scenario would be so helpful!! Thanks so much. Sue Susan Cooke MSN RN NEA-BC Sepsis Program Coordinator University Medical Center New Orleans 2000 Canal Street New Orleans, LA 70112 O 504.702.2924 F 504.702.2119 [email protected]@LCMChealth.org<mailto:[email protected]@LCMChealth.org> umcno.org [umcno.org]<https://urldefense.com/v3/__https:/www.umcno.org/__;!!K_I4mMC9zg!_EMzvlbnCvKV8nznfT2cpda55LkM1BXtdx3f10ZqhZR8LVKBHf3TrN1g5Z3f$>
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