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One of our hospitalist says "elevated lactate" should be enough to represent organ dysfunction when coding for severe sepsis. Any thoughts? does anyone know where I can find a list of diagnosis that fit this criteria?Thanks
This would be a very hard sell if you coded it this way if this case was audited. The patient must clearly meet the definition of severe sepsis otherwise it will be denied. On a coding stand point the specific organ dysfunction needs to be mentioned and linked to the sepsis. Also, elevated lactate is not a really a good reason either as this is just an abnormal lab value.
To me unless the doctor states a possible organ dysfunction as the cause of the elevated lab results this could not be coded as severe sepsis even though it may truly be severe sepsis based on the physicians clinical judgement and we are not to challenge his judgement either but as a coders we must follow our own guidelines.