Sepsis: Understand clinical presentation and coding strategies for ICD-10
A 12-year-old male developed umbilical discomfort Monday and didn't eat much dinner. On Tuesday, he started vomiting at school and the pain shifted to his right lower quadrant. His parents brought him to the ED, where his vital signs showed:
- Temperature of 102.4
- Pulse rate of 100
- Respiration of 16 breaths per minute
- White blood cell count of 18,000
The physician's exam showed localized tenderness with rebound in the right lower quadrant with rectal tenderness referred to the right lower quadrant.
The surgeon diagnosed acute appendicitis and prescribed a dose of Levaquin IV. The surgeon then took the patient to the operating room Tuesday and removed a purulent, non-perforated appendix. The patient ate well on Wednesday and was discharged home on no antibiotics. He returned to school three days after discharge.
Did this patient have sepsis, defined as systemic inflammatory response syndrome (SIRS) plus infection?
The answer is no, says Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta.
"The patient certainly had acute intra-abdominal infection, fever, and elevated white blood cell count, so an infection and two of the four criteria of SIRS," Gold says. The patient was not started on a "sepsis bundle" but was given a dose of antibiotic preoperatively; he was discharged 24 hours after surgery with no antibiotics.
To correctly code for sepsis, coding professionals also need to understand the clinical presentation of sepsis.
Editor's note: This article is an excerpt from "Sepsis: Understand clinical presentation and coding strategies for ICD-10," which published in the October edition of Briefings on Coding Compliance Strategies.