Q&A: Conflicting documentation of sepsis and bacteremia

Q: I recently was reviewing a chart where the infection control physician stated the patient had sepsis, but the attending listed bacteremia as the diagnosis. I sent a query to clarify which was correct and the attending confirmed bacteremia. On the discharge summery, though, sepsis was still listed. Will the discharge summary supersede the physician’s answer to the query?

A: Believe it or not, in many situations, attendings use the term “bacteremia” to imply sepsis. Clinically, the physician may not be differentiating the diagnoses as two different things, even though coding does. 

Now, bacteremia is the principal diagnosis, it won’t change your DRG, though it could certainly affect quality concerns and medical necessity. It’s important to remember that bacteremia by the coding definition does not generally meet medical necessity for an inpatient admission because it implies the patient is asymptomatic with a self-limiting condition that requires little to no treatment. The result is that you may actually have to place a second query to confirm the physician does not indeed mean sepsis when he answered “bacteremia.”

There are however, all sorts of nuances to this. For example, the patient may have initially been septic with positive blood cultures and no longer has indicators for sepsis upon discharge, but they may still have a positive repeat blood cultures.  The clinical truth of that scenario is that sepsis was the principle diagnosis, present, and treated, while the ongoing bacteremia at discharge is still significant enough to require documentation (as the patient may have to be on antibiotic coverage for weeks or even months). This explains why the physician answered the way he did, but this won’t allow the coders to code the record appropriately.  A query will have to be placed to get this fully clarified so that sepsis can be reported.

Another possibility is that the patient was never truly septic and only had positive blood cultures and the attending’s documentation will lead to accurate ICD-10 code assignment without further query.  This scenario will occasionally result in a legitimate need for an admission as IV antibiotics are required to clear the blood stream and there is no viable alternative to admission to the patient’s insurance (or lack of) and their socio-economic circumstances.

A third possible scenario is that when the attending says “bacteremia,” he or she actually means “sepsis with positive blood cultures.” In which case, you need not only another query, but also to provide education for the physician. 

Remember the clinical validation of sepsis is always of utmost importance as not every patient with sepsis indicators is septic.  Not every patient with positive blood cultures is septic.  There are many “false positives” which may occur due to the patient’s pre-existing disease states as well as confounding factors from other new onset acute conditions which must be considered properly in the context of the patient. 

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.