Documentation Tip: Sepsis Syndrome

DocumentPlease remember that per coding guidelines, the term “SEPSIS SYNDROME” is not adequate to code SEPSIS. Please refrain from using this phrase when referring to the subset of symptoms generally associated with SEPSIS. When this phrase is seen in documentation, the CDS or Coder will be required to submit a query to the physician to clarify the diagnosis. Suggested documentation of Sepsis is (for example): “presents with leukocytosis and fever, suspect UTI as source, meets criteria for Sepsis.”

 
Systemic Inflammatory Response Syndrome (SIRS) is defined as two or more of the following:
Fever
Tachycardia
Tachypnea
Leukocytosis
SIRS with a (suspected) infectious source = SEPSIS
SEPSIS with Organ Dysfunction = SEVERE SEPSIS

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