CCDS Sepsis Criteria and Documentation (Sepsis-3) 2 — Questions and Answers
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?
- SOFA score increase of 1 point from baseline
- SOFA score increase of 2 or more points from baseline (Correct answer)
- SOFA score of 4 or greater at any time
- SOFA score of 6 or greater with documented bacteremia
Correct answer: SOFA score increase of 2 or more points from baseline
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.
Sepsis-3 defines sepsis as life-threatening organ dysfunction due to a dysregulated host response to infection. Organ dysfunction is operationally defined as an acute change in total SOFA score of 2 or more points from baseline, attributable to infection. The SOFA score evaluates respiratory, coagulation, liver, cardiovascular, CNS, and renal systems.
Question 2: The quick SOFA (qSOFA) score includes which three clinical criteria?
- Fever above 38 degrees C, WBC above 12,000/mm3, heart rate above 90 bpm
- Altered mentation, respiratory rate at or above 22 per minute, systolic blood pressure at or below 100 mmHg (Correct answer)
- Lactate above 2 mmol/L, systolic BP below 90, temperature below 36 degrees C
- WBC below 4,000, creatinine above 2.0, bilirubin above 2.0 mg/dL
Correct answer: Altered mentation, respiratory rate at or above 22 per minute, systolic blood pressure at or below 100 mmHg
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.
The quick SOFA tool was introduced with Sepsis-3 as a rapid bedside screening tool for suspected sepsis requiring no lab values. The three components are: altered consciousness (GCS 13 or less or new disorientation), elevated respiratory rate (22 per minute or more), and low systolic blood pressure (100 mmHg or less).
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?
- N39.0 - Urinary tract infection, site not specified
- A41.9 - Sepsis, unspecified organism (or organism-specific A40-A41 code) (Correct answer)
- R65.20 - Severe sepsis without septic shock
- T81.4 - Infection following a procedure
Correct answer: A41.9 - Sepsis, unspecified organism (or organism-specific A40-A41 code)
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.
ICD-10-CM Official Guidelines Section I.C.1.d specify that for patients admitted with sepsis, the appropriate code from category A40 or A41 should be sequenced first. The site of infection (UTI with N39.0) is coded as an additional diagnosis.
Question 4: Septic shock is defined under Sepsis-3 as sepsis with which two additional criteria?
- Systolic BP below 90 mmHg AND lactate above 2 mmol/L
- Circulatory failure requiring vasopressors to maintain MAP at or above 65 mmHg AND lactate above 2 mmol/L despite adequate fluid resuscitation (Correct answer)
- Temperature below 36 degrees C AND vasopressor requirement alone
- Positive blood cultures AND systolic BP below 70 mmHg
Correct answer: Circulatory failure requiring vasopressors to maintain MAP at or above 65 mmHg AND lactate above 2 mmol/L despite adequate fluid resuscitation
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.
The Sepsis-3 septic shock definition requires both a MAP at or above 65 mmHg only maintainable with vasopressors AND a serum lactate above 2 mmol/L despite adequate volume resuscitation. ICD-10-CM codes this as R65.21 (Severe sepsis with septic shock), sequenced after the sepsis organism code.
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?
- Accept 'bacteremia' and code A49.01 or A49.02 (Staphylococcal infection without sepsis)
- Query the physician to clarify whether the clinical presentation meets criteria for sepsis (Correct answer)
- Code sepsis directly since positive blood cultures indicate sepsis by definition
- Code only the source of infection since bacteremia is always a secondary diagnosis
Correct answer: Query the physician to clarify whether the clinical presentation meets criteria for sepsis
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.
Bacteremia is distinct from sepsis. The clinical scenario provides clinical indicators that support querying for sepsis, but the physician must confirm. If the physician documents sepsis, A41.01 (MRSA) or A41.02 (MSSA) would be coded based on the Staphylococcus species.
Question 6: Why is documentation of lactate levels particularly important in sepsis cases from a CDI perspective?
- Lactate levels determine which organism code (A40 vs. A41) should be assigned
- Elevated lactate (above 2 mmol/L) is one of two criteria required to code septic shock under Sepsis-3 (Correct answer)
- Lactate above 4 mmol/L is required before sepsis can be coded as a diagnosis
- Lactate documentation is required by CMS before a sepsis diagnosis is reimbursable
Correct answer: Elevated lactate (above 2 mmol/L) is one of two criteria required to code septic shock under Sepsis-3
Under Sepsis-3, lactate above 2 mmol/L despite adequate resuscitation is one of the two criteria required for septic shock (the other being vasopressor dependence).
Lactate serves two important roles in sepsis CDI: as a clinical indicator supporting a sepsis query, and as a specific criterion for septic shock coding. If lactate is above 2 mmol/L despite resuscitation AND vasopressors are required for MAP maintenance, septic shock (R65.21) can be coded rather than just severe sepsis (R65.20).
CCDS Sepsis Criteria and Documentation (Sepsis-3) 2
Under the Sepsis-3 definition, what is the minimum SOFA score change required to define organ dysfunction in the context of suspected infection?