Hi Susan, Based on the information provided, the abstractor is correct. Discharge summary is not used for any inclusion terms, present on admission terms, SIRS or OD criteria. This piece of documentation is not reviewed for CMS SEP-1 bundle of care. It is an essential piece for coders when POA makes a significant impact on other measures especially sepsis mortality.
Coders and abstractors do not follow the same guidelines. Abstractors only review charts that are already coded after d/c following CMS specification manual. These guidelines are usually updated once or twice a year by CMS. We need to understand that any chart coded as 'sepsis, unsp orgn A41.9" will end up in CMS SEP-1 population. There are about 27 ICD-10 codes for SEP-1 population that might pull any chart with any one of these codes into population. What the abstractor does, is reviews each chart based on CMS guidelines provided looking for 2SIRS, 1 organ dysfunction and infection criteria or an inclusion term regardless of how it was coded. The only approved inclusion terms are: severe sepsis, septic shock, severe sepsis with shock. There is a list of organ dysfunction criterion approved by CMS in the manual. All documentation is taken at face value. AMS and encephalopathy has never been listed as organ dysfunction criteria under CMS specification manual. I have been doing SEP-1 abstraction from its beginning. While entire chart is available to review, there are certain data elements that only limit acceptable documentation to 3, 6, 24, 48 or 72 hours. Sepsis is not the same as severe sepsis and has been confused a lot. CMS has included 'sepsis' and 'septic' as acceptable terms for infection only. By abstraction guidelines, if there is no provider documentation of an inclusion term AND no presence of CMS approved organ dysfunction criteria, there is no presence of severe sepsis as time zero for severe sepsis cannot be established. Thus, the chart is excluded from sepsis denominator. You may find the CMS Specification Manual, v.5.9 (January 1, 2021-June 30, 2021 discharges) here: https://qualitynet.cms.gov/inpatient/specifications-manuals Click on alphabetical data dictionary and search for Severe sepsis presentation data element where organ dysfunction criterion, inclusion terms and other guidelines are listed. There are also appendices with ICD-10 codes, medication tables for antibiotics references and others. I hope this helps. Please let me know if you have any other questions. Marina Zhukov, RN, BSN Sepsis Data Abstractor Ask me about Sepsis! Office Hours: M-Th 1149 Market Street, Tacoma, WA 98402 | MS 10-04 P. 253.552.5782 | I. 152-5782 [email protected]<mailto:[email protected]> From: Sepsisgroups [mailto:[email protected]] On Behalf Of Cooke, Susan Sent: Wednesday, February 03, 2021 2:02 PM To: [email protected] Subject: Re: [Sepsis Groups] I need some clarification and would appreciate some input USE CAUTION - EXTERNAL EMAIL ________________________________ 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.com/v3/__https:/www.umcno.org/__;!!CqLityr3mSQ!U59kQkflbIryOWymd7WrxfX-n6VrXYgvzi3uCWBw83LrXiu94FrAwGlVvJ8wpGtcuvYP0aTD$> From: Cooke, Susan Sent: Wednesday, February 3, 2021 10:41 AM To: [email protected]<mailto:[email protected]> Subject: I need some clarification and would appreciate some input Hi everybody, I am going round and round with our Abstracting company related to a UTI sepsis case. Patient came to ED meeting SIRS criteria and a change in mental status which was reported as definitely improved after antibiotic administration. The Bundle elements were met. The coding was for Sepsis and UTI with a primary of Altered Mental Status. All were POA. The Abstractors excluded the case because they say the patient did have evidence of organ dysfunction because CMS does not recognize Altered Mental Status as Organ dysfunction (but SCCM does). 1. Is this correct that the case should be excluded even though the patient clearly had sepsis. Improved with antibiotics and it was coded as such by the physician? 2. In my email to the Abstractor I had mentioned (because I'm somewhat new to this level of detail and didn't realize the altered mental status wasn't an organ dysfunction) that it was clearly stated in the Discharge Summary that the patient had Altered Mental Status that improved with Antibiotics and the source was a UTI. I was told that -Also,any documentation in the discharge summary is not to be used to determine the presence of severe sepsis/septic shock. Is this true? Isn't the entire chart a possible source for a sepsis diagnosis? Any insight to this type of scenario would be so helpful!! Thanks so much. Sue Susan Cooke MSN RN NEA-BC Sepsis Program Coordinator University Medical Center New Orleans 2000 Canal Street New Orleans, LA 70112 O 504.702.2924 F 504.702.2119 [email protected]@LCMChealth.org<mailto:[email protected]@LCMChealth.org> umcno.org<https://urldefense.com/v3/__https:/www.umcno.org/__;!!CqLityr3mSQ!U59kQkflbIryOWymd7WrxfX-n6VrXYgvzi3uCWBw83LrXiu94FrAwGlVvJ8wpGtcuvYP0aTD$> Caution: This email is both proprietary and confidential, and not intended for transmission to (or receipt by) any unauthorized person(s). If you believe that you have received this email in error, do not read any attachments. Instead, kindly reply to the sender stating that you have received the message in error. Then destroy it and any attachments. Thank you.
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