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There have been many attempts to redefine sepsis and septic shock to create the most consistent diagnoses, which would help physicians to diagnose early and code for the disease appropriately. It is difficult to define and diagnose, as the symptoms that can trigger a diagnostic test are similar to many other infections. The challenging nature of the condition highlights the need for a consistent definition accepted by all physicians. In its simplest form of the CDC’s definition, “sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency.”

Sepsis has placed an immense toll on the people it affects and the healthcare system as a whole. Sepsis was the cause of hundreds of millions of hospitalizations in the United States between 1979 through 2000, with an estimated cost of $17 billion annually during that time, and “killing 20 to 50 percent of severely affected patients.” According to the CDC, in a typical year, 1.7 million adults in America develop sepsis, with nearly 350,000 dying of the disease. Sepsis makes up one in three patient deaths in a hospital. Sepsis makes up 1 in 3 patient deaths in a hospital.

Sepsis makes up 1 in 3 patient deaths in a hospital.

Despite the prevalence of sepsis in America, fewer than half of Americans have heard of this disease, according to the CDC. The need for more awareness is why, in 2011, the Sepsis Alliance designated September as Sepsis Awareness Month. The month is not to just bring attention to the adults suffering from this disease, but also the children who develop it. After a change in the definition in 2016, a separate task force was set up to establish guidelines for sepsis in pediatric patients. This was the plan set forth by the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM), because as SCCM notes:

“Population-based studies of the prevalence of pediatric sepsis estimate 72-89 cases per 100,000 pediatric population in the United States, with over 50,000-75,000 hospitalizations for pediatric sepsis and an associated cost near $5 billion annually… Over 4% of all hospitalized patients younger than 18 years and 8% of pediatric intensive care unit (PICU) patients in the United States have sepsis.”

The goal of the guidelines set up by the SCCM was to allow for earlier detection of sepsis in children, many of whom are very vulnerable as their immune systems have not fully developed. The SCCM released a new set of guidelines and best practices for diagnosing and treating sepsis in children in February 2020.

The guidelines provided by the SCCM focused on creating better outcomes for children through early detection and protocols to focus treatment and recognition. Pediatricians must understand these guidelines and the diagnostic tools necessary to diagnose the problem earlier, as there can be an improvement in mortality overall.

Consistent protocols also have the added benefit, when pediatricians are familiar with coding and clinical documentation improvement (CDI) with sepsis, of diagnosing sepsis at an earlier stage in its development and creating a better patient outcome through this knowledge. Then, with the added help of an experienced coding and clinical documentation integrity partner, like Accuity, the coding plan for sepsis can be standardized within an organization.

Protecting the integrity of your care with AI that thinks clinically

Accuity’s AI-driven clinical model analyzes every record to identify gaps, signals, and discrepancies between the care delivered and the final coded record. 

By aligning both documentation and coding with the reality of care, Accuity improves clinical quality metrics and financial accuracy — ensuring the final coded record reflects the true clinical reality.

This standardization will help keep healthcare professionals aligned with the diagnosis, treatment, and coding of sepsis to focus on healing the vulnerable children in the world.

Clinical documentation is a necessary process for every hospital’s bottom line. It’s the foundation for payer reimbursement and drives the best patient care outcomes throughout the episode of care. Mistakes in clinical documentation are a real problem for hospitals and have led to millions of dollars in missed revenue.

Even when the documentation is complete, the accuracy and complexity of actual care can get lost. Small disconnects can hide clinical nuance, which means payers can quietly keep the difference. These hidden losses cost the average health system $2–$6 million per 10,000 inpatient discharges.

The source of clinical documentation starts with the physician. The purpose of this work is to document the true clinical picture of care and can put a health system at risk if done improperly.

In a 2013 paper, Adele L. Towers, MD, MPH, said, “Physicians are not taught how to complete the documentation to accurately assign codes, and physician billing does not require a high degree of specificity…however, the lack of specificity on a hospital record can affect payment. The key is to engage physicians to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided.”

While this is an important aspect for any hospital, for the physician, the most common response to why a physician may feel the effects of burnout is that they are buried in administrative processes and tasks. Physician burnout is a work-related syndrome involving emotional exhaustion, depersonalization and a sense of reduced personal accomplishment. This problem represents a public health crisis with negative impacts on individual physicians, patients and healthcare organizations.

According to the AMA, “Physician burnout is costing the U.S. about $4.6 billion annually when you conservatively estimate the costs related to physician turnover and reduced clinical hours.”

However, in the age of AI technology, physician burnout and its related costs can be significantly reduced. Clinically driven AI engines redefine documentation by combining expert judgement with machine precision to deliver a more accurate picture of care.

Physician-led AI has the ability to analyze every chart to surface clinical signals, codable clues, and missed opportunities where clinical reality is most often lost in translation between medicine and coding. Put simply, these AI engines reveal where clinical reality isn’t fully reflected in the coded record.

AI finds the signals, interprets the complexity, and revenue cycle teams sustain the results.

AI technology does not ask physicians to document more — on the contrary, it helps reduce administrative burden and empowers physicians. Through transparent updates and trend-based education, AI reduces unnecessary queries over time and makes remaining queries more clinically meaningful. The result is a final coded record that accurately reflects the actual care delivered.

The strength of a physician’s clinical documentation not only helps ensure that a hospital will be reimbursed for the accurate clinical scenario, but it also benefits the health of the patient beyond the encounter in which it was made. Physician education in AI clinical documentation is critical to realizing better health outcomes and hospital performance.

Learn more about Amplifi, Accuity’s customized, physician-led documentation program.

Leveraging clinical perspectives to power the middle revenue cycle—insights that drive impact.

In today’s fast-moving digital healthcare landscape, staying ahead of clinical updates, coding changes, and revenue cycle trends is more critical—and more accessible—than ever. Chart Checkup, Accuity’s new podcast, brings you fresh perspectives and expert insights that make a difference where it counts: the middle revenue cycle.

Join us as we explore the latest developments with physicians, CDI professionals, and industry leaders—including Accuity’s own clinical and revenue integrity experts. Each episode dives into timely topics designed to inform and empower healthcare professionals.

Topics include:

Whether you’re a CDI specialist, coder, physician advisor, clinician or healthcare executive, Chart Checkup will keep you informed, inspired, and ahead of the curve.

Listen on your favorite podcast platform or at https://accuitychartcheckup.buzzsprout.com/

Encephalopathy is not a single disease but a disorder of cellular metabolism. Whether it is a lack of oxygen, a chemical imbalance, a metabolic dysfunction, dysregulation, or a toxic environment, the brain cells cannot function, leading to neurological symptoms.

Although most cases are temporary, the capture of encephalopathy is critical for documentation accuracy and to capture the complexity of the patient’s encounter. To accurately translate cases involving this diagnosis into coding and avoid cumbersome denials, coders and CDI specialists must thoroughly understand what to look for in clinical documentation. Physicians can help by using precise and codable terminology in their documentation.

Unraveling a diagnosis such as encephalopathy can be a daunting task due to the numerous types and the many twists and turns it can take clinically. I’ve outlined five core concepts to help anyone navigate the complexity of an encephalopathy case.

5 types of encephalopathy

  1. Metabolic Encephalopathy is an acute condition arising from a metabolic disturbance within the body that alters mental status.
  2. Toxic Encephalopathy can appear as a result of a reaction from a prescribed medication, illicit drugs, over-the-counter drugs, or a toxin such as vapors or toxic solutions and is also considered an acute condition.
  3. Hepatic Encephalopathy arises from a form of liver dysfunction such as cirrhosis or hepatitis. It is usually accompanied by an elevated ammonia level, which is often responsible for the acute alteration of mental status.The other scenario that can occur is when a patient has a progression of their underlying liver disease, resulting in an acute alteration of mental status that is remedied by increasing specific medication regimens.
  4. Hypertensive Encephalopathy occurs as a result of an acute hypertensive episode and can serve as an end-organ dysfunction in a hypertensive emergency or crisis.
  5. Static Encephalopathy is a chronic permanent state of a patient suffering from chronic epilepsy. This is not to be confused with transient (acute) alteration in mental status (AMS) during the post-ictal state that follows seizure activity, as this is considered integral to the seizure.

Acute forms of encephalopathy occur more frequently than chronic. There are numerous terms used in medical documentation for an encephalopathic process. Still, one should also consider coding rules, clinical symptoms, and regulatory enforcement of clinical validation, which comes from the False Claims Act, meaning that there must be sufficient clinical indicators to support billing for any encephalopathy.

5 key concepts for navigating encephalopathy documentation

Encephalopathy is diffuse by nature.

Per the National Institute of Neurological Disorders and Stroke, Encephalopathy is considered a ‘diffuse’ condition, indicating that the problem occurs as a widespread pathology within the brain that can’t be pinpointed.

Imaging results are expected to be negative.

Because encephalopathy is defined as a diffuse condition, an abnormality should not be identified on imaging via CT scan or MRI.

One exception we must consider is the AHA Coding Clinic fourth quarter, 2018, page 16, which states that encephalopathy can be due to a cerebrovascular accident (CVA). CVAs are identifiable on imaging except for embolic showers, which require more time to build up the density needed to be identified on a head CT scan or MRI. Although this coding clinic’s direction appears to be the opposite of the medical definition, we cannot ignore the AHA Coding Clinic.

Many interpret it as: If the symptoms are due to direct damage (i.e. dysarthria due to fronto/temporal stroke) encephalopathy is not appropriate. However, global diffuse altered mental status due to the general dysfunction of the steady state of the brain, which dissipates after time and treatment, may be captured as encephalopathy.

Identifying the cause is necessary.

Encephalopathy is always due to an underlying etiology, so the next step after imaging is to follow working differentials to identify the underlying cause.

The underlying etiology must improve with treatment.

Once the underlying etiology is identified, the next step is to determine if the treatment for the underlying etiology improves the encephalopathic process that resulted in an altered mental state.

If the patient’s alteration in mental status (AMS) does not improve once treatment for the underlying condition is implemented, there are two possibilities. Either the underlying etiology is incorrect, and the treating providers must return to the drawing board and work up the clinical differentials again, or the patient doesn’t have encephalopathy, and something else is happening.

The patient must return to mental status baseline.

The last core concept is that if the patient’s mental status has improved once treatment for the underlying cause was treated, the patient should return to their normal mental status baseline.

When a patient with dementia is admitted for AMS, a dementia baseline should be documented to allow for a CDI specialist to measure the patient’s return to baseline. This core concept is the clinical validating piece that supports the diagnosis of whichever type of acute encephalopathy is being addressed.

Conundrum cases

I can’t speak about encephalopathy without addressing a few twists and turns that make this diagnosis challenging to capture accurately.

One particularly challenging scenario is when a patient with dementia is admitted with an alteration in mental status. Often, the patient resides in a nursing home and wakes up altered, making it necessary to transport the patient to the emergency room, where a UTI is identified. For this class of patients, the only way to measure the return to baseline is to have a documented mental status baseline for dementia.

Another problematic scenario is when two different forms of encephalopathy are superimposed on each other. This gets tricky as one would need to identify an underlying etiology for each one to validate the diagnoses clinically.

Conclusion and additional resources

Regardless of the scenario, if the five core concepts outlined above are considered, along with referring to applicable AHA coding clinics and coding conventions, processing these cases will be more straightforward. Accuity’s clinical capture experts have created this tip sheet as an additional support tool.

In clinical documentation, cases often arise that are commonly difficult to accurately diagnosis and document. Coagulation happens to be a condition that is a documentation challenge for physicians and CDI teams alike. 

Accuity’s education team, Dr. Lynn Miller and Kelly Burns, CCS, were featured on the ACDIS Podcast to examine how hospitals can better identify coagulation pathways, which can manifest in multiple forms, from traumatic DIC to thrombophilia in weight loss surgery to new board coagulopathy. 

“Coagulopathy is incorrectly assumed to be a problem with clotting and increased risk of bleeding usually due to impaired clot formation,” said Dr. Miller. “But really it’s any derangement of hemostasis, which is the true definition of coagulopathy.” 

Listen to the ACDIS Podcast now.

Listen to the ACDIS Podcast to hear Dr. Miller and Kelly offer tips to help your CDI teams comb through charts for coagulopathy clinical indicators. They also dive into the importance of examining the big picture of a patient’s history and social determinants of health so that CDI teams have strong clinical background knowledge to capture this difficult diagnosis. They also offer tips to writing effective queries surrounding a coagulation diagnosis. 

Dr. Lynn Miller, a Board-Certified Adult and Pediatric Neurosurgeon, left a full-time surgical practice to join Accuity and is now leads Accuity’s education team as Director of Education. Dr. Miller earned her undergraduate and graduate degrees from Michigan State University and has Fellowship status in the American College of Osteopathic Surgeons. She also holds Board Certification in Integrative Medicine and continues to work on her Fellow status within Wilderness Medicine. This creates a nice blend of professional growth with exciting travel opportunities and family adventure, both additional favorite pastimes.

Pertinent to her work at Accuity, Dr. Miller has developed and implemented educational events and programs within academic arenas, medical facilities, and medical device corporations prior to joining Accuity’s education team. She also has extensive knowledge regarding the revenue cycle particularly from a surgical and implant perspective.