Coders may find assigning codes for sepsis somewhat easier in ICD-10-CM, but they will still face some challenges. The first of those challenges, and probably the biggest, centers on physician documentation.
All pressure ulcers are wounds, but not all wounds are pressure ulcers. A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Wounds usually break or cut the skin.
How well could you code in ICD-10 using your current physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?
If you're not already actively using your hospital's PEPPER (Program for Evaluating Payment Patterns Electronic Report), you're missing out on a lot of valuable data.
Over and over, one gets frustrated that professional coders are told that they are smart and educated and know about anatomy, physiology, and pharmacology, and then the same people turn around and say, "You code what the doctor documented and it's not up to you to question the physician."
