Confused on what to code
I am auditing a record where a 54 year old female patient came into the ER (12/1/09) with sudden complaint of confusion and weakness. She reported she had some chest pain the prior day. Pt has a history of coronary artery disease and is S/P CABG. Her WBC is 11,500 with 33 bands, urinalysis reveals 3+ bacteria. BP is 42/22. Pt is suspected of significant sepsis with metabolic acidosis.
She was placed in ICU and started on dopamine, about 3:00pm. She was also given IV Zosyn and IV vancomycin in the ER. Blood cultures were collected. About 10:00pm patient suddenly went into cardia arrest. After considerable resuscitation efforts, she developed sinus tachycardia. With Levophen for blood pressure support, she had a systolic blood pressure of 120. Pt was intubated. The prior day family said patient had a temperature of 105.
After 15-20 minutes, pt arrested again. She was revived with considerable resuscitative efforts. She again about 20 mins after the recovery went into bradycardia, loss of bp and responded to resuscitative efforts. The oulook was ominous. Pt had a very poor prognosis. She continued to decline with cardiac arrest on the basis of severe septic state.
Family opted for DNR status. Measures were continued, pt again arrested and lost her bp and heart rate. Patient expired due to severe sepsis.
The timing for the whole process was not recorded but yet it was coded as a level 2 CC.
What should I coded this as?
Physician Chart Auditor