tci ED Coding & Reimbursement Alert - 2009 Issue 9

You Be the Coder : Getting to the Bottom of a SIRS Service

Question: A patient reports to the ED with complaints of fever, decreased urine output, and a skin rash. Suspecting sepsis, the ED physician orders a twoview chest x-ray, inserts a Foley catheter (due to nurse difficulty with the procedure), and orders blood collection for testing. After reviewing the labs and x-ray results, the physician detects impaired oxygen availability in the patient's blood; final diagnosis is "SIRS, no organ dysfunction." What condition does this note describe, and what services can I report separately from the E/M service? Oregon Subscriber Answer: The patient has a form of sepsis, which you'll...

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