This page addresses follow-up questions and additional information pertinent to our webinar
Sepsis CDI Education: Prove It, Support It, Defend It.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.
Q: When the medical record contains documentation of the diagnosis of sepsis in the progress notes written by the attending. The infectious disease consultant writes, “bacteremia.”
How do I, as a CDI, handle this conflicting documentation?
A: A query is imperative in this situation to quantify if the patient is being monitored, treated, or evaluated for sepsis, bacteremia, or possibly both.
The attending’s diagnosis is typically used in the coding summary; however, if a consultant offers a conflicting diagnosis, a query is necessary.
Q: The provider has documented sepsis in the progress notes. You, as the CDI, understand that the payer for this patient requires Sepsis 3 as a diagnosis. What should you do?
A: The CDI specialist can issue a query requesting the provider to add additional clinical indicators to further clarify the sepsis 3 diagnosis. Never add payer information to a query.
This may be a good opportunity to discuss the case with the provider in person, helping them understand the criteria used by this payer.
Q: The patient has been inpatient for 5 days. There is now clinical evidence of sepsis. Upon a review of the admitting history and physical as well as the progress notes, there are no clinical indicators present for sepsis. What would I do as a CDI?
A: Query the provider for POA status.
Meet the Presenter: Lisa Romanello, MSHI, BSN,RN, CCDS,CCDS-O
With three decades of experience as a bedside nurse in oncology, orthopedics, neurology, cardiology, and rehab, Lisa transitioned into Clinical Documentation Improvement (CDI) after her nursing career. She served as the manager of a CDI program spanning two Level 1 trauma center campuses, gaining deep expertise in hospital operations and documentation compliance. Following seven years in hospital CDI management, she moved into consulting, helping organizations nationwide establish new inpatient and outpatient CDI programs, as well as revitalize and expand existing programs. During this time, she earned a Master of Science in Health Informatics, supporting EMR transitions and optimizing clinical workflows. She has extensive experience providing education for physicians, CDI teams, physician advisors, and coding professionals, combining clinical insight with documentation and compliance expertise.
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