CCDS Sepsis Criteria and Documentation (Sepsis-3) 4 — Questions and Answers
Question 1: Under Sepsis-3, which statement best describes the role of SIRS criteria in diagnosing sepsis?
- SIRS criteria remain required to meet the sepsis definition
- SIRS criteria were eliminated from the Sepsis-3 definition (Correct answer)
- SIRS criteria are optional supplemental findings under Sepsis-3
- SIRS criteria apply only to surgical patients under Sepsis-3
Correct answer: SIRS criteria were eliminated from the Sepsis-3 definition
Sepsis-3 (2016) abandoned SIRS criteria in favor of organ dysfunction identified by an acute SOFA score increase ≥2.
Question 2: A patient with suspected infection has a serum lactate of 3.2 mmol/L but no hypotension. How should the CDI specialist query this?
- Query for septic shock because lactate alone defines it
- Query for sepsis only, as hypotension is required for septic shock
- Query for septic shock because lactate ≥2 mmol/L meets the definition even without hypotension (Correct answer)
- No query is needed; elevated lactate is not a sepsis criterion
Correct answer: Query for septic shock because lactate ≥2 mmol/L meets the definition even without hypotension
Septic shock under Sepsis-3 can be diagnosed when lactate >2 mmol/L persists despite adequate resuscitation, even without hypotension.
Question 3: A physician documents 'urosepsis' for a patient with a UTI and fever but no organ dysfunction. What is the CDI specialist's best action?
- Accept the documentation as it meets Sepsis-3 criteria
- Query the physician because Sepsis-3 requires evidence of organ dysfunction (Correct answer)
- Query only if the patient required ICU admission
- Code urosepsis as a secondary diagnosis without querying
Correct answer: Query the physician because Sepsis-3 requires evidence of organ dysfunction
Sepsis-3 requires life-threatening organ dysfunction in addition to infection, so 'urosepsis' without organ dysfunction should prompt a clarification query.
Question 4: Which ICD-10-CM code is sequenced FIRST when sepsis is the reason for admission and pneumonia is the underlying infection?
- J18.9 (Pneumonia, unspecified)
- A41.9 (Sepsis, unspecified organism) (Correct answer)
- R65.20 (Severe sepsis without septic shock)
- R65.21 (Severe sepsis with septic shock)
Correct answer: A41.9 (Sepsis, unspecified organism)
When sepsis is the principal diagnosis and the underlying infection is also coded, sepsis is sequenced first per UHDDS and ICD-10-CM guidelines.
Question 5: A patient develops sepsis 72 hours after hip arthroplasty. Which POA indicator applies to the sepsis diagnosis?
- Y – present on admission
- N – not present on admission (Correct answer)
- W – clinically undetermined
- U – documentation insufficient to determine
Correct answer: N – not present on admission
Sepsis developing 72 hours post-admission was not present on admission and should be assigned POA indicator 'N'.
Question 6: When a patient meets Sepsis-3 criteria and also has acute respiratory failure, what is the correct coding approach?
- Code only sepsis; respiratory failure is integral
- Code sepsis as principal and acute respiratory failure as an additional diagnosis (Correct answer)
- Code acute respiratory failure first, then sepsis
- Code R65.20 (Severe sepsis) which captures respiratory failure implicitly
Correct answer: Code sepsis as principal and acute respiratory failure as an additional diagnosis
ICD-10-CM guidelines direct coders to assign additional codes for any associated acute organ dysfunction, including acute respiratory failure, alongside the sepsis code.
Question 7: Which documentation element is MOST critical for supporting a septic shock diagnosis for quality and reimbursement purposes?
- Administration of broad-spectrum antibiotics within 1 hour
- Explicit physician attestation of septic shock in the final diagnosis (Correct answer)
- Blood culture results positive for a pathogen
- Insertion of a central venous catheter
Correct answer: Explicit physician attestation of septic shock in the final diagnosis
For coding purposes, explicit physician documentation of 'septic shock' in the final diagnosis—not just treatment indicators—is required to assign the diagnosis.
CCDS Sepsis Criteria and Documentation (Sepsis-3) 4
Under Sepsis-3, which statement best describes the role of SIRS criteria in diagnosing sepsis?