AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Issue 1; Ask the Editor
Transfer to the Long-Term Care Hospital for Resolving Sepsis
This patient was admitted from acute care to the long-term care hospital (LTCH) with ongoing treatment of Clostridium difficile (C. difficile) colitis, chronic obstruction pulmonary disease (COPD) exacerbation and asthma. One of the physician’s admitting and discharge diagnoses is: sepsis, resolving. Is it appropriate to assign a code for “resolving sepsis”? Does it matter if the patient is treated with antibiotics? ...
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Article Overview
This article addresses a documentation and coding question encountered in long-term care hospital transfers, where sepsis is described as resolving alongside ongoing treatment for other conditions. It explains the general approach to reviewing the record when the septic condition is no longer active, emphasizes the role of documentation clarity, and discusses when provider clarification may be needed. The piece is aimed at coders, CDI staff, and billing professionals working with inpatient and post-acute records.
Why This Topic Matters
Sepsis documentation is often clinically and administratively sensitive, and unclear status can affect diagnosis capture and record accuracy. Understanding how to interpret resolving terminology and when to seek clarification helps support consistent coding and cleaner physician documentation.
What You Will Learn
- How to evaluate documentation that describes sepsis as resolving
- How coding decisions may depend on the clarity of the documented clinical status
- Why provider clarification may be needed when documentation is ambiguous
- How documentation practices affect record accuracy in post-acute settings
Who Should Read This
- Medical coders
- Clinical documentation improvement (CDI) specialists
- Inpatient and post-acute billing staff
- Health information management (HIM) professionals
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