A patient with fever, hypotension, leukocytosis, and heavy bacterial growth in urine is documented as urosepsis, but the physician’s documentation is unclear about sepsis. What is the next step for the coding professional?

• A. Query the physician to determine if the patient is being treated for sepsis, highlighting the clinical signs and symptoms.
• B. Code the septicemia based on laboratory data.
• C. Add an addendum to the chart.
• D. Document as sepsis in the problem list.

Answer: (A)

When coding, a diagnosis must be explicitly documented by the clinician to be coded as such. If the chart shows signs that could support sepsis (fever, hypotension, leukocytosis, heavy bacterial growth in urine) but the physician’s notes don’t clearly state that sepsis is diagnosed or being treated, the next step is to obtain clarification through a targeted physician query. This ensures the coder assigns sepsis only if it is actually diagnosed and documented, or codes the underlying infection if sepsis isn’t confirmed.

Querying the physician to confirm whether the patient is being treated for sepsis (and to document the presence or absence of sepsis explicitly) prevents misclassification. Coding septicemia based solely on lab data isn’t appropriate because labs alone don’t establish the clinical diagnosis, and terms like septicemia are not used to justify a sepsis code without physician confirmation. Adding an addendum or marking the problem list with sepsis without explicit documentation could misrepresent the patient’s condition. Once the physician clarifies, the coder can assign the correct sepsis code (if present) or the appropriate infection code if sepsis is not diagnosed.