CCDS Sepsis Criteria and Documentation (Sepsis-3) 4

Question 1

Under Sepsis-3, which statement best describes the role of SIRS criteria in diagnosing sepsis?

Accepted Answer

SIRS criteria were eliminated from the Sepsis-3 definition

Answer

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?

Accepted Answer

Query for septic shock because lactate ≥2 mmol/L meets the definition even without hypotension

Answer

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?

Accepted Answer

Query the physician because Sepsis-3 requires evidence of organ dysfunction

Answer

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?

Accepted Answer

A41.9 (Sepsis, unspecified organism)

Answer

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?

Accepted Answer

N – not present on admission

Answer

Sepsis developing 72 hours post-admission was not present on admission and should be assigned POA indicator 'N'.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Sepsis Criteria and Documentation (Sepsis-3) 4