A walk-in clinic assessment states ‘SIRS due to pneumonia’ and does not document sepsis. Nursing triage notes mention possible sepsis criteria. How should the coder proceed?
Select an answer to reveal the explanation.
Short Explanation
Code what the clinician actually called it—not what the vitals might tempt you to assume. SIRS with pneumonia isn’t a free upgrade to sepsis without the provider saying so. If sepsis isn’t documented, don’t invent it.
Full Explanation
ICD-10-CM code assignment must reflect provider-documented diagnoses. Systemic inflammatory response related to a localized infection is not coded as sepsis unless sepsis is documented (or clarified via a compliant query when documentation is conflicting or incomplete). Nursing impressions alone do not establish sepsis. Coders follow the assessment language and Official Guidelines rather than clinical criteria checklists by themselves.