AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Issue 4; Ask the Editor

Severe Sepsis and Acute Organ Dysfunction/Failure

The AHA Central Office has received several questions whether sepsis with any acute organ dysfunction is assumed to be linked by the term “with” or if the physician must directly link it with the sepsis to code as severe sepsis. Providers are documenting conditions such as, but not limited to, hypoperfusion, hyperbilirubinemia, lactic acidosis, encephalopathy, thrombocytopenia, hypoxia and hypotension, etc., as an acute organ dysfunction in severe sepsis. Is it appropriate to report severe sepsis with acute organ dysfunction when the provider has documented conditions, such as hyperbilirubinemia, but has not explicitly linked the conditions? ...

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