Understanding the anatomy, physiology and disease process is a significant part of our daily work and competencies as Health Information Management (HIM) coding and Clinical Documentation Integrity (CDI) professionals. Thus, keeping on top of clinical information like that of Sepsis and COVID-19 is particularly important as it can certainly aid in determining when to query the provider.

Sepsis has been a medical challenge for several years now and then came COVID-19 a year ago which brought even greater challenges.  A January 28th, 2021 clinical article was released by Critical Care Medicine titled: Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU. As we have all seen and heard many adults with COVID-19 have progressed to having Sepsis and a need for the Intensive Care Unit (ICU). A prior article was published in March 2020 in Critical Care Medicine on this same subject; thus, the January 2021 article provides some updated information and recommendations for clinicians, some of which is within this blog.

The Surviving Sepsis Campaign (SSC) on Coronarvirus Disease 2019 gathered a panel of clinical experts to look at the guidelines for the ICU management of adults with severe or critical COVID-19. It should be noted that the panel used the World Health Organization’s (WHO) definition of severe and critical COVID-19.

From a clinical perspective the SSC panel identified and recommended nine key points; three are new and six were updated which are included in the full article details. The panel recommendations included the following noteworthy treatment options:

  • Use of systemic corticosteroids and venous thromboprophylaxis for patient with severe or critical COVID-19 but recommends against use of hydroxychloroquine.
  • Suggests using dexamethasone over other corticosteroids.
  • Suggests against using convalescent plasma outside of clinical trials.
  • Suggests against the use of empiric therapeutic anticoagulation outside of clinical trials.
  • No recommendations were made on the use of awake prone positioning, due to insufficient evidence at this time.

Dr Laura E. Evans, MD, MS, FCCM provides a short video on the SSC website regarding this panel findings and the new guideline recommendations. In addition, the panel produced a table to summarize their clinical recommendations and suggestions which you can access at: SSC-COVID19GuidelinesRecTable-FirstUpdate.pdf (sccm.org)

Go to the following link to review the article summary: https://journals.lww.com/ccmjournal/Abstract/9000/Surviving_Sepsis_Campaign_Guidelines_on_the_.95371.aspx

As HIM coding and CDI professionals we have a major role and function to read through medical record documentation, which includes but is not limited to physician progress notes, orders, and even clinical protocols.  This medical record clinical documentation paints the picture of the patient’s condition and/or illness and is vital to the translation into medical codes (ICD-10-CM/PCS and CPT) and data.

Documentation and coding of Sepsis and COVID-19 is an area that should be on your list for auditing in 2021. We sure to check with your audit team, compliance leadership and/or external consultants for support.  Do not wait to begin these focused audits in order to identify any gaps or vulnerabilities.  Another key action to take is to obtain and/or provide education on the documentation and coding of these conditions.

Written by: Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

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