The clinical documentation improvement team has reviewed three different charts in the past month that included the diagnosis of urosepsis. There is NO CODE for urosepsis on its own. This term is ambiguous and nonspecific for coding purposes.
Our advice: Reflect the severity of illness in the patient’s chart — your patient should look as sick “on paper” as they look in the hospital bed.
To avoid getting a query, you can either document UTI, or, if the patient meets sepsis criteria, “sepsis secondary to UTI.”
Thanks to all of our providers for your time and attention in ensuring accurate patient records, which improves patient care.