CCDS Sepsis Criteria and Documentation (Sepsis-3) 5 — Questions and Answers
Question 1: A CDI specialist notes that a physician used 'SIRS due to non-infectious cause' in the chart. Under Sepsis-3, how should this be treated for coding?
- Code as sepsis because SIRS and sepsis are equivalent
- Code the specific non-infectious condition; SIRS due to non-infectious cause is not coded in ICD-10-CM
- Code R65.10 (SIRS of non-infectious origin without acute organ dysfunction) (Correct answer)
- Query the physician to change the terminology to sepsis
Correct answer: Code R65.10 (SIRS of non-infectious origin without acute organ dysfunction)
ICD-10-CM retains R65.1x codes for SIRS of non-infectious origin, which is coded separately from sepsis (A40-A41 range).
Question 2: Which clinical scenario BEST illustrates the Sepsis-3 concept of 'life-threatening organ dysfunction'?
- Fever of 38.5°C and WBC of 13,000 with a positive blood culture
- Acute rise in serum creatinine of 1.5 mg/dL above baseline in a patient with bacteremia (Correct answer)
- Localized cellulitis with tachycardia and leukocytosis
- Positive urinalysis and body temperature of 38.1°C
Correct answer: Acute rise in serum creatinine of 1.5 mg/dL above baseline in a patient with bacteremia
Sepsis-3 defines organ dysfunction as an acute SOFA score increase ≥2, and an acute creatinine rise reflects renal dysfunction contributing to that score.
Question 3: A hospitalist documents 'sepsis secondary to C. difficile colitis.' Which ICD-10-CM code combination is correct?
- A41.9, A04.72 (Correct answer)
- A04.72, A41.9
- A41.9 alone (C. diff is integral)
- R65.20, A04.72
Correct answer: A41.9, A04.72
ICD-10-CM guidelines sequence sepsis (A41.9) first when it is the principal diagnosis, followed by the underlying infection (A04.72 for C. diff colitis).
Question 4: A patient admitted for sepsis is also documented to have disseminated intravascular coagulation (DIC). What additional code is assigned?
- No additional code; DIC is bundled into the sepsis code
- D65 – Disseminated intravascular coagulation (Correct answer)
- R65.20 – Severe sepsis without septic shock (DIC elevates it)
- D68.9 – Coagulation defect, unspecified
Correct answer: D65 – Disseminated intravascular coagulation
DIC is an associated organ dysfunction that must be coded separately (D65) in addition to the sepsis code per ICD-10-CM guidelines.
Question 5: Under the Surviving Sepsis Campaign 1-hour bundle, which action should be completed FIRST for a patient meeting sepsis criteria?
- Administer vasopressors
- Measure lactate level (Correct answer)
- Obtain echocardiogram
- Insert a urinary catheter for strict I&O
Correct answer: Measure lactate level
The 1-hour bundle begins with measuring lactate, which guides resuscitation targets and risk-stratifies the patient for septic shock.
Question 6: A CDI query asks the physician to clarify whether a patient with bacteremia and a SOFA score increase of 2 has 'sepsis.' What is the clinical basis for this query?
- Bacteremia alone always qualifies as sepsis under Sepsis-3
- A SOFA increase ≥2 in the setting of suspected infection meets the Sepsis-3 definition (Correct answer)
- The query is inappropriate because only intensivists can diagnose sepsis
- A SOFA of 2 is below the threshold; the cutoff is ≥4
Correct answer: A SOFA increase ≥2 in the setting of suspected infection meets the Sepsis-3 definition
Sepsis-3 defines sepsis as suspected or confirmed infection plus an acute total SOFA score increase of ≥2 points above baseline.
Question 7: Which of the following is a key difference between the ICD-10-CM definition of 'severe sepsis' (R65.2x) and the Sepsis-3 clinical definition?
- ICD-10-CM severe sepsis requires bacteremia; Sepsis-3 does not
- Sepsis-3 eliminated the term 'severe sepsis'; ICD-10-CM retains it for coding purposes (Correct answer)
- ICD-10-CM severe sepsis requires a SOFA score ≥4; Sepsis-3 uses ≥2
- There is no difference; ICD-10-CM updated to mirror Sepsis-3 in 2017
Correct answer: Sepsis-3 eliminated the term 'severe sepsis'; ICD-10-CM retains it for coding purposes
Sepsis-3 eliminated 'severe sepsis' as a clinical category, but ICD-10-CM continues to use R65.20/R65.21 for coding organ dysfunction associated with sepsis.
CCDS Sepsis Criteria and Documentation (Sepsis-3) 5
A CDI specialist notes that a physician used 'SIRS due to non-infectious cause' in the chart.
Under Sepsis-3, how should this be treated for coding?