Extended criteria (experimental).
This is the broader ten-condition engine, kept as a secondary area. It shows ICD-10-CM codes and illustrative grouping effects
for CDI staff. The primary surface is Before you sign (kidney, measurement only).
All extended pages.
← Back to the worklist · Whole encounter ENC-00030
Camila Merriweather: Sepsis
ENC-00030 · 72M · Hospital Medicine · admitted Sun Nov 08, 2026 02:47 PM · discharged Wed Nov 11, 2026 11:14 AM · attending Dr. Kenji Stavros · resident Dr. Camila Oyelaran
Clinical validation gap Criteria not met Open
Contested definitions (Sepsis-2 vs Sepsis-3)
Documented “sepsis” (A41.9) but the criteria are not met: Neither definition met: 0 SIRS criteria, SOFA change 0.
Documented vs supported
- Documented
- “sepsis” · A41.9 Sepsis, unspecified organism
- Criteria support
- criteria not met
- Outcome
- Neither definition met: 0 SIRS criteria, SOFA change 0
- Rule
- Sepsis (clinical validation; Sepsis-3 and Sepsis-2 shown side by side) v2026.11-1
- Published source
- The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), Singer et al., JAMA 2016;315:801-810 (2016), Boxes 3-4: sepsis = infection + acute change in total SOFA >=2 (baseline 0 unless known); septic shock = vasopressors for MAP >=65 and lactate >2 mmol/L despite adequate volume · source (checked 2026-11-14)
- Contested
- CONTESTED DEFINITIONS. Sepsis-3 (organ dysfunction, SOFA) is the current consensus definition; Sepsis-2 (SIRS) is still used by the CMS SEP-1 quality measure and by many payers' clinical-validation policies. When the two disagree this rule never concludes: it returns "clinical judgement required (definition-dependent)". ICD-10-CM guideline I.A.19: code assignment is based on the provider's statement, not on clinical criteria; clinical validation is a separate process. The rule validates documented sepsis only and never prompts for an undocumented sepsis diagnosis.
Effect if the clinician agrees (illustrative)
- Change
- principal A41.9 removed; N39.0 becomes principal
- Secondary-diagnosis level
- principal → removed
- MS-DRG (illustrative)
- 871 Septicemia or severe sepsis without MV >96 hours with MCC → 689 Kidney and urinary tract infections with MCC
- Relative weight
- 1.9425 → 1.1603 (-0.7822)
- Codes before
- A41.9, N39.0, E66.9, I50.33, I10, E78.5, E11.9
- Codes after
- N39.0, E66.9, I50.33, I10, E78.5, E11.9
All open gaps on this encounter together: MS-DRG 871 → 689 (RW -0.7822).
CC/MCC status, CC exclusions (subset) and relative weights from the public CMS FY2026 IPPS final rule tables (5, 6I, 6J, 6K). This is not a grouper and not a payment estimate. Queries never mention any of this.
Severity documentation index change SIMULATED
-0.5 points
SIMULATED: Illustrative severity weights (MCC = 1.0, CC = 0.5, non-CC = 0) summed over secondary diagnoses; not a validated risk-adjustment model and not a measured effect.
Evidence
Structured values are read by code from the cited rows. Note facts are shown only when the model's quote was found verbatim in the note.
| Input | Value | Source |
|---|---|---|
| Infection quoted from a note or an infection principal diagnosis | True |
“urinary tract infection”
Show the quote in the note… ervice: Hospital Medicine Attending: Dr. Kenji Stavros
History of present illness: 72-year-old man admitted with sepsis. Urinalysis with pyuria; treated for urinary tract infection with cefepime.
Past medical history: heart failure with preserved ejection fraction, hypertension, hyperlipidemia, type 2 diabetes.
Review of systems otherwise …
principal diagnosis A41.9
|
| Highest temperature, first 48 h (C) | 37.5 |
temperature 37.5 °C
|
| Lowest temperature, first 48 h (C) | 36.7 |
temperature 36.7 °C
|
| Highest heart rate, first 48 h | 88.0 |
heart rate 88/min
|
| Highest respiratory rate, first 48 h | 20.0 |
respiratory rate 20/min
|
| Highest WBC, first 48 h (x10^3/uL) | 9.32 |
WBC 9.32 x10^3/uL
|
| Lowest WBC, first 48 h (x10^3/uL) | 7.52 |
WBC 7.52 x10^3/uL
|
| Lowest platelets, first 48 h (x10^3/uL) | 174.0 |
platelets 174 x10^3/uL
|
| Highest bilirubin, first 48 h (mg/dL) | 0.72 |
bilirubin 0.72 mg/dL
|
| Lowest mean arterial pressure, first 48 h (mmHg) | 75.0 |
MAP 75 mmHg
|
| Highest norepinephrine-equivalent dose, first 48 h (mcg/kg/min) no vasopressor in the first 48 hours |
0.0 | derived (no vasopressor in the first 48 hours) |
| Lowest Glasgow Coma Scale, first 48 h | 15.0 |
GCS 15
|
| Highest creatinine, first 48 h (mg/dL) | 2.81 |
creatinine 2.81 mg/dL
|
| Baseline creatinine (mg/dL), for the baseline renal SOFA score most recent pre-admission value within 365 days |
2.69 |
creatinine 2.69 mg/dL (pre-admission)
|
Rule trace (inputs, thresholds, outcome)
| Step | Expression | Inputs and thresholds read | Result |
|---|---|---|---|
| derived: sirs_temp | coalesce(temp_max_48h > t.t_hi, false) or coalesce(temp_min_48h < t.t_lo, false) |
t.t_hi=38, t.t_lo=36, temp_max_48h=37.5, temp_min_48h=36.7 | false |
| derived: sirs_hr | coalesce(hr_max_48h > t.hr, false) |
hr_max_48h=88.0, t.hr=90 | false |
| derived: sirs_rr | coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false) |
paco2_min_48h=unknown, rr_max_48h=20.0, t.paco2=32, t.rr=20 | false |
| derived: sirs_wbc | coalesce(wbc_max_48h > t.wbc_hi, false) or coalesce(wbc_min_48h < t.wbc_lo, false) or coalesce(bands_max_48h > t.bands, false) |
bands_max_48h=unknown, t.bands=10, t.wbc_hi=12, t.wbc_lo=4, wbc_max_48h=9.32, wbc_min_48h=7.52 | false |
| derived: sirs_count | count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc) |
sirs_hr=False, sirs_rr=False, sirs_temp=False, sirs_wbc=False | 0 |
| derived: sofa_resp | coalesce(case(pf_min_48h < 100 and adv_resp_support, 4, pf_min_48h < 200 and adv_resp_support, 3, pf_min_48h < 300, 2, pf_min_48h < 400, 1, 0), 0) |
adv_resp_support=False, pf_min_48h=unknown | 0 |
| derived: sofa_coag | coalesce(case(platelets_min_48h < 20, 4, platelets_min_48h < 50, 3, platelets_min_48h < 100, 2, platelets_min_48h < 150, 1, 0), 0) |
platelets_min_48h=174.0 | 0 |
| derived: sofa_liver | coalesce(case(bili_max_48h >= 12, 4, bili_max_48h >= 6, 3, bili_max_48h >= 2, 2, bili_max_48h >= 1.2, 1, 0), 0) |
bili_max_48h=0.72 | 0 |
| derived: sofa_cardio | coalesce(case(norepi_max_48h > 0.1, 4, norepi_max_48h > 0, 3, map_min_48h < 70, 1, 0), 0) |
map_min_48h=75.0, norepi_max_48h=0.0 | 0 |
| derived: sofa_cns | coalesce(case(gcs_min_48h < 6, 4, gcs_min_48h < 10, 3, gcs_min_48h < 13, 2, gcs_min_48h < 15, 1, 0), 0) |
gcs_min_48h=15.0 | 0 |
| derived: sofa_renal | coalesce(case(creat_max_48h >= 5, 4, creat_max_48h >= 3.5, 3, creat_max_48h >= 2, 2, creat_max_48h >= 1.2, 1, 0), 0) |
creat_max_48h=2.81 | 2 |
| derived: sofa_renal_baseline | coalesce(case(creat_baseline >= 5, 4, creat_baseline >= 3.5, 3, creat_baseline >= 2, 2, creat_baseline >= 1.2, 1, 0), 0) |
creat_baseline=2.69 | 2 |
| derived: sofa_delta | sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline |
sofa_cardio=0, sofa_cns=0, sofa_coag=0, sofa_liver=0, sofa_renal=2, sofa_renal_baseline=2, sofa_resp=0 | 0 |
| derived: sepsis3 | infection_documented and sofa_delta >= t.sofa_delta |
infection_documented=True, sofa_delta=0, t.sofa_delta=2 | false |
| derived: sepsis2 | infection_documented and sirs_count >= t.sirs_min |
infection_documented=True, sirs_count=0, t.sirs_min=2 | false |
| derived: shock | sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false) |
lactate_max_48h=unknown, norepi_max_48h=0.0, sepsis3=False, t.lactate=2 | false |
| outcome: no_infection | not infection_documented |
infection_documented=True | false |
| outcome: septic_shock | shock |
shock=False | false |
| outcome: both | sepsis3 and sepsis2 |
sepsis2=False, sepsis3=False | false |
| outcome: sepsis3_only | sepsis3 |
sepsis3=False | false |
| outcome: definitions_disagree | sepsis2 |
sepsis2=False | false |
| outcome: neither | true |
— | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2016); clinical indicators and answer options assembled by code from the rule and the record.
Sign in to act. Sign in as a demo user (a CDI specialist sends queries).
DOCUMENTATION QUERY (draft) Title: Clarification request: infection-related documentation Encounter: ENC-00030 Patient: Camila Merriweather To: Dr. Kenji Stavros Clinical indicators from the health record: - Documented in the record: "sepsis" [History and physical DOC-000100] - "urinary tract infection" (2026-11-08 17:47) [History and physical DOC-000100, p. 1, line 5] - principal diagnosis A41.9 [encounter ENC-00030] - temperature 37.5 °C (2026-11-09 23:07) [vital VIT-002964] - temperature 36.7 °C (2026-11-08 15:07) [vital VIT-002948] - heart rate 88/min (2026-11-08 15:07) [vital VIT-002949] - respiratory rate 20/min (2026-11-09 07:07) [vital VIT-002935] - WBC 9.32 x10^3/uL (2026-11-10 05:00) [lab LAB-001035] - WBC 7.52 x10^3/uL (2026-11-09 05:00) [lab LAB-001033] - platelets 174 x10^3/uL (2026-11-09 05:00) [lab LAB-001034] - bilirubin 0.72 mg/dL (2026-11-08 15:47) [lab LAB-001039] - MAP 75 mmHg (2026-11-08 15:07) [vital VIT-002950] - GCS 15 (2026-11-08 15:07) [vital VIT-002951] - creatinine 2.81 mg/dL (2026-11-10 05:00) [lab LAB-001020] - creatinine 2.69 mg/dL (pre-admission) (2026-09-04 10:05) [lab LAB-001017] Question: The indicators above are documented in this encounter. Could you clarify the status of the documented infection-related diagnosis? Response options (select one or write your own): ( ) Sepsis: confirmed (please document the supporting clinical information) ( ) Sepsis: ruled out ( ) Other explanation of the clinical findings (please specify): ____________ ( ) Unable to determine Please respond based on your independent clinical judgement. Any response, including "unable to determine", is acceptable. This query and your response are kept as part of the health record.
Other findings on this encounter
- Chronic kidney disease · Specificity gap Criteria support Chronic kidney disease stage 4 (N18.4); no corresponding diagnosis is documented.
- Obesity · Specificity gap Documented “obesity” (E66.9); criteria support the more specific Obesity, class 1 (E66.811).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2016 | 2026-11-14T20:57:23 | system:llm system |
llm.call |
ENC-00030, ENC-00030.sepsis | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt dab1a4e3e8a2 output 4be4a07a71b8 entry addcb7fdbaf7 |
| 1190 | 2026-11-14T19:24:28 | system:llm system |
llm.call |
ENC-00030, ENC-00030.sepsis | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt dab1a4e3e8a2 output 4be4a07a71b8 entry 167bb2ca3ddc |
| 448 | 2026-11-14T18:29:03 | system:llm system |
llm.call |
ENC-00030, ENC-00030.sepsis | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt dab1a4e3e8a2 output 4be4a07a71b8 entry 5ce7a52db0e9 |