Coding sepsis Question Title * 1. Are you experiencing ongoing "coding issues" surrounding the coding of sepsis? Yes No Not sure Comments Question Title * 2. If you answered yes to question 1, please indicate which of the following best captures the issues you are having (otherwise, skip to question 4): Documentation Coding index Coding guidelines Comments Question Title * 3. If you answered that "Documentation" is an issue, please indicate one or more of the following if they apply (otherwise, skip to question 4) Clinical indicators are not documented but diagnosis of sepsis is listed Clinical indicators are contrasting with diagnosis of sepsis Documentation is only in the ED note and not by the attending Clinical criteria for SIRS are documented, but not the word "sepsis" EHR Documentation is "cut/pasted" from another encounter of the patient into present encounter/admission Comments Question Title * 4. Are you experiencing the following? Physicians are identifying SIRS in every case where two of the four criteria of SIRS are present and never linking them to an inflammatory cause. Yes No Not sure Comments Question Title * 5. What do you do when a physician documents SIRS and the patient has an infection such as acute appendicitis or the flu and goes home in two days on no antibiotics? Assign 038.9 as principal diagnosis Query the physician whether the patient has sepsis Ignore the documentation of SIRS and assign the code for acute appendicitis or flu as principal diagnosis Assign 995.91 as a secondary diagnosis with acute appendicitis or flu as principal diagnosis but not 038.9 Comments Question Title * 6. Are your CDI team and your coding staff working together on documentation issues such as sepsis? Yes, we meet an average of at least once month Yes, but we meet an average of once per quarter No Not sure Comments Question Title * 7. Have you or your organization received any Recovery Auditor/MAC or other regulatory requests on sepsis medical records? Yes No Not sure Comments Done