FREE CCDS Sepsis Criteria and Documentation (Sepsis-3) Questions and Answers

Question 1

According to the Sepsis-3 consensus definition, sepsis is best described as:

Accepted Answer

Life-threatening organ dysfunction caused by a dysregulated host response to infection.

Answer

Sepsis-3 defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. This definition shifts the focus from inflammation (SIRS) to the life-threatening nature of the body's response.

Question 2

Which of the following clinical findings is a component of the quick Sequential Organ Failure Assessment (qSOFA) score?

Accepted Answer

Altered mental status

Answer

The qSOFA score is a bedside tool to identify patients with suspected infection who are at greater risk for a poor outcome. Its three components are respiratory rate ≥ 22/min, altered mental status (GCS < 15), and systolic blood pressure ≤ 100 mm Hg.

Question 3

The Sepsis-3 definition of septic shock requires persisting hypotension needing vasopressors to maintain a MAP ≥ 65 mm Hg and what other finding?

Accepted Answer

A serum lactate level > 2 mmol/L after fluid resuscitation

Answer

Septic shock is a subset of sepsis with profound circulatory, cellular, and metabolic abnormalities. It is identified by the need for vasopressors for hypotension and a serum lactate level > 2 mmol/L despite adequate fluid resuscitation.

Question 4

A physician documents 'sepsis due to pneumonia' and 'acute kidney injury' in separate parts of the record. For coding purposes, what is required to link the AKI to the sepsis?

Accepted Answer

Explicit provider documentation linking the two conditions.

Answer

Official coding guidelines require the provider to explicitly link organ dysfunction to sepsis. A CDS should send a query to clarify if the AKI is a manifestation of the sepsis, using language such as 'acute kidney injury due to sepsis'.

Question 5

A patient is admitted for sepsis. If the source of the infection is known (e.g., pneumonia), how should the diagnoses be sequenced?

Accepted Answer

Sequence the code for sepsis first, followed by the code for the localized infection.

Answer

Per official coding guidelines, if the reason for admission is sepsis and a localized infection, the systemic infection (sepsis) should be sequenced first. The localized infection (e.g., pneumonia) is sequenced as a secondary diagnosis.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

FREE CCDS Sepsis Criteria and Documentation (Sepsis-3) Questions and Answers