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

SOFA score increase of 1 point from baseline

Answer

SOFA score of 4 or greater at any time

Answer

SOFA score of 6 or greater with documented bacteremia

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

Fever above 38 degrees C, WBC above 12,000/mm3, heart rate above 90 bpm

Answer

Lactate above 2 mmol/L, systolic BP below 90, temperature below 36 degrees C

Answer

WBC below 4,000, creatinine above 2.0, bilirubin above 2.0 mg/dL

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

N39.0 - Urinary tract infection, site not specified

Answer

R65.20 - Severe sepsis without septic shock

Answer

T81.4 - Infection following a procedure

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

Systolic BP below 90 mmHg AND lactate above 2 mmol/L

Answer

Temperature below 36 degrees C AND vasopressor requirement alone

Answer

Positive blood cultures AND systolic BP below 70 mmHg

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

Accept 'bacteremia' and code A49.01 or A49.02 (Staphylococcal infection without sepsis)

Answer

Code sepsis directly since positive blood cultures indicate sepsis by definition

Answer

Code only the source of infection since bacteremia is always a secondary diagnosis

Question 6

Why is documentation of lactate levels particularly important in sepsis cases from a CDI perspective?

Accepted Answer

Elevated lactate (above 2 mmol/L) is one of two criteria required to code septic shock under Sepsis-3

Answer

Lactate levels determine which organism code (A40 vs. A41) should be assigned

Answer

Lactate above 4 mmol/L is required before sepsis can be coded as a diagnosis

Answer

Lactate documentation is required by CMS before a sepsis diagnosis is reimbursable