Q&A: Finding sepsis where there is none

Q: We recently reviewed a troubling case related to sepsis core extractions which revealed that the patient did not have sepsis and the physicians did not document sepsis as there was no bacterial infection. The CDI specialist, however, queried for severe sepsis twice. Finally, the admitting/discharging physician agreed and signed the query stating severe sepsis was present.

The attending physician is distraught that the CDI specialist queried the physician twice and wore down the admitting/discharging physician. They both agree there was no sepsis on this case but felt the CDI specialist forced this diagnosis. The patient did, however, have multiple diagnoses and met SIRS criteria.

A: You’re right to be concerned for a number of reasons. First, if in your review you have determined that sepsis was not present (which removes severe sepsis as well), the provider should amend the record to remove the diagnosis and it should be rebilled with the appropriate diagnoses.

I would also apologize to the provider and explain that CDI specialists should never query if the clinical indicators do not support the diagnosis, and should not have harassed or forced the issue. The provider should understand the motivation of the CDI program and that querying is done to ensure the documentation is clear and specific to the situation. My providers often asked me, “What do you want me to write?” My standard answer was, “I want you to write what is true to this patient, this encounter. Nothing more, nothing less.”

The last thing is understanding the motivation of this specific CDI specialist. Did the CDI specialist think that sepsis and severe sepsis were truly present? If so, I would provide education related to the clinical criteria used to diagnose sepsis and severe sepsis. I would also take the opportunity to speak about compliant query practice, and reiterate that CDI specialists should never prod a provider to write something they do not agree with.

As to who is responsible for the final diagnosis, the coder must code the diagnoses identified by the provider. When the diagnoses are not clinically supported, a query should be placed to verify and identify clinical support. The CDI specialists should be working to ensure that the coder is handed a record in which these issues are clearly documented. But, a CDI specialist should never lead a provider to a specific diagnosis or force the provider to document a diagnosis that is not present.

Lastly, the manager in me thinks perhaps auditing this specific staff member’s queries might be a good idea to make sure compliant practices are being followed in daily activities.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, and CDI education specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.