Ugh. I feel your frustration - unfortunately, this is correct.

CMS does not recognize AMS as a sign of organ dysfunction.
Only criteria for organ dysfunction (with nuances, of course...) include:
bili >2, or
Cr > 2, or
PLT < 100K, or
INR > 1.5, or
PTT > 60, or
Lactate > 2, or
MAP < 65, or
BP < 90 or
use of ventilation device for acute illness (BiPap/intubation); so 'bipap at 
night' doesn't count.

Had the provider(s) documented severe sepsis or septic shock anywhere, that 
would override the criteria and start the time zero clock.

....I'm not familiar with the lack of use of data in the discharge summary.... 
Sometimes, the discharge summary is the only place our providers will add 
"sepsis" as a diagnosis. By doing so, this will officially drop the patient 
into the sepsis DRG and it's available for abstraction. So then if the patient 
meets source, 2/4 SIRS, 1 OD, then it would most certainly be abstracted.

I'd love to hear other perspectives on the discharge summary.

Hope this helps.

Thanks,
Danette

PS - the altered mental status should not stop the providers and nurses from 
clinically determining sepsis/severe sepsis/septic shock. At Norton we built 
our sepsis screening tool for nursing to include the abnormality of altered 
mental status as a SIRS criteria. To date, it's not been brought to my 
attention that we've over captured or inappropriately screened for sepsis by 
adding this piece.

Danette Culver, MSN, APRN, ACNS-BC, CCRN-K, RN-BC
Clinical Nurse Specialist
Norton Healthcare
4967 U.S. Hwy 42, Suite 100
Louisville, KY 40222
O: 502.420.4371
C: 812.881.0080

A Clinical Nurse Specialist (CNS) is a Master's prepared Advance Practice Nurse 
whose function is to improve outcomes in patient care. The CNS is a clinical 
practice expert, an educator, a researcher, and a consultant who influences the 
three spheres of practice: patient care, nursing, and systems. - National 
Association of Clinical Nurse Specialists


From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of Cooke, Susan
Sent: Wednesday, February 03, 2021 5:02 PM
To: [email protected]
Subject: [EXTERNAL] Re: [Sepsis Groups] I need some clarification and would 
appreciate some input

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________________________________
I'm sorry I mean to say the Abstractor said the patient did NOT have evidence 
of organ failure because CMS does not recognize AMS as organ dysfunction so 
they did not proceed with examining the case for compliance because it did not 
meet SEV-SEP criteria. They placed it in the Excluded column.

Thanks


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<https://urldefense.proofpoint.com/v2/url?u=https-3A__www.umcno.org_&d=DwMFAg&c=a-fTYuyacsOBdK5dxJm0TrOrF1BT4RdAkNRqW_Js53o&r=JPxSALmxUy5xyHEOvdym-hyL93XcvJhDCEPFRYF80a7aoNWBQpBALyYxCgapSd3h&m=JT2wq76NNB2UxSwqmd-M_O9cP4kGSnfm_Uvr8VJeOkY&s=0As6wVqyTkbZoQsm1-Eu_HkjhzJV8rWTNaStyzO1HRA&e=>



From: Cooke, Susan
Sent: Wednesday, February 3, 2021 10:41 AM
To: 
[email protected]<mailto:[email protected]>
Subject: I need some clarification and would appreciate some input

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<https://urldefense.proofpoint.com/v2/url?u=https-3A__www.umcno.org_&d=DwMFAg&c=a-fTYuyacsOBdK5dxJm0TrOrF1BT4RdAkNRqW_Js53o&r=JPxSALmxUy5xyHEOvdym-hyL93XcvJhDCEPFRYF80a7aoNWBQpBALyYxCgapSd3h&m=JT2wq76NNB2UxSwqmd-M_O9cP4kGSnfm_Uvr8VJeOkY&s=0As6wVqyTkbZoQsm1-Eu_HkjhzJV8rWTNaStyzO1HRA&e=>



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