CCDS Sepsis Criteria and Documentation (Sepsis-3) 5

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?

Accepted Answer

Code R65.10 (SIRS of non-infectious origin without acute organ dysfunction)

Answer

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'?

Accepted Answer

Acute rise in serum creatinine of 1.5 mg/dL above baseline in a patient with bacteremia

Answer

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?

Accepted Answer

A41.9, A04.72

Answer

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?

Accepted Answer

D65 – Disseminated intravascular coagulation

Answer

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?

Accepted Answer

Measure lactate level

Answer

The 1-hour bundle begins with measuring lactate, which guides resuscitation targets and risk-stratifies the patient for septic shock.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Sepsis Criteria and Documentation (Sepsis-3) 5