If documentation of severe sepsis is unclear upon admission, what action should the coder take?

When documentation of severe sepsis is unclear upon a patient's admission, the appropriate action for the coder is to query the provider for clarification. This step is essential because accurate coding relies on clear and specific documentation from the healthcare provider. By seeking clarification, the coder ensures that they have the correct information to code the condition appropriately, which is crucial for both quality of care and proper reimbursement.

Consulting the provider helps to prevent any assumptions about the patient's condition, which could lead to inaccurate coding. Without clear documentation, coders may misinterpret clinical information, resulting in errors that could impact patient records, hospital reporting, and compliance with coding guidelines. Therefore, querying the provider maintains the integrity of the coding process and ensures adherence to the complexities of medical billing practices.