What should a coder do if a provider uses a nonspecific term related to sepsis?

When a provider uses a nonspecific term related to sepsis, it is essential for the coder to query the provider for clarification. This is because nonspecific terminology does not provide adequate information for accurate coding, which can lead to undercoding or overcoding. Seeking clarification ensures that the final code accurately reflects the patient's condition and aligns with clinical documentation.

By asking the provider for more details, the coder can identify the precise nature and severity of the sepsis, which is necessary for assigning the most specific and appropriate ICD-10-CM code. This practice also supports compliance with coding guidelines and improves data accuracy for reporting and billing purposes. When coders rely on nonspecific terms without seeking further information, it could result in coding errors that impact patient care, reimbursement, and the overall integrity of healthcare data.