CCDS Sepsis Criteria and Documentation (Sepsis-3) 2

Question 1

Under the Sepsis-3 definition, what is the minimum SOFA score change required to define organ dysfunction in the context of suspected infection?

Accepted Answer

SOFA score increase of 2 or more points from baseline

Answer

The Sepsis-3 definition (2016) defines sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, where organ dysfunction is operationally defined as a SOFA score increase of 2 or more points from baseline.

Question 2

The quick SOFA (qSOFA) score includes which three clinical criteria?

Accepted Answer

Altered mentation, respiratory rate at or above 22 per minute, systolic blood pressure at or below 100 mmHg

Answer

The qSOFA score uses three bedside criteria: altered mentation (GCS below 15), respiratory rate at or above 22 breaths per minute, and systolic blood pressure at or below 100 mmHg. A qSOFA score of 2 or more identifies patients at higher risk for sepsis-related organ dysfunction.

Question 3

Under ICD-10-CM sepsis coding guidelines, which code is sequenced FIRST when a patient is admitted with sepsis due to a urinary tract infection?

Accepted Answer

A41.9 - Sepsis, unspecified organism (or organism-specific A40-A41 code)

Answer

Per ICD-10-CM guidelines, when sepsis is present, the systemic infection code (A41.x or A40.x for the specific organism) is sequenced as the principal or first-listed diagnosis. The localized infection (UTI) is coded as an additional diagnosis.

Question 4

Septic shock is defined under Sepsis-3 as sepsis with which two additional criteria?

Accepted Answer

Circulatory failure requiring vasopressors to maintain MAP at or above 65 mmHg AND lactate above 2 mmol/L despite adequate fluid resuscitation

Answer

Sepsis-3 defines septic shock as a subset of sepsis with vasopressor requirement to maintain MAP at or above 65 mmHg AND serum lactate above 2 mmol/L despite adequate fluid resuscitation.

Question 5

A patient is admitted with fever, chills, elevated WBC, and blood cultures positive for Staphylococcus aureus. The physician documents 'bacteremia.' How should the CDI specialist proceed?

Accepted Answer

Query the physician to clarify whether the clinical presentation meets criteria for sepsis

Answer

Bacteremia refers to bacteria in the bloodstream and does not automatically equate to sepsis. The clinical picture (fever, chills, elevated WBC, positive cultures) may meet sepsis criteria. The CDI specialist should query the physician to clarify.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Sepsis Criteria and Documentation (Sepsis-3) 2