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.

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Mara Pemberton: Sepsis

ENC-00061 · 47F · Hospital Medicine · admitted Sun Nov 08, 2026 09:24 AM · in hospital · attending Dr. Rosalind Quillan · resident Dr. Elena Nakashima

Specificity gap Criteria met Open In hospital: concurrent review Resident note awaiting attending cosign Contested definitions (Sepsis-2 vs Sepsis-3)

Documented “sepsis” (A41.9); criteria support the more specific Sepsis with septic shock (R65.21).

Documented vs supported

Documented: “sepsis” · A41.9 Sepsis, unspecified organism
Criteria support: Sepsis with septic shock · R65.21 Severe sepsis with septic shock
Outcome: Sepsis-3 septic shock: SOFA change 5, vasopressor and lactate 3.8
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 -> R65.21
Secondary-diagnosis level: principal → principal
MS-DRG (illustrative): 871 Septicemia or severe sepsis without MV >96 hours with MCC → None Other
Relative weight: —
Codes before: A41.9, J18.9, I50.23, E87.1
Codes after: R65.21, J18.9, I50.23, E87.1

All open gaps on this encounter together: MS-DRG 871 → ? .

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

0.0 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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Infection quoted from a note or an infection principal diagnosis	True	“multifocal pneumonia” · History and physical DOC-000211, p. 1, line 5 · quoted span verified Show the quote in the note … 11-08 09:24 Service: Hospital Medicine Attending: Dr. Rosalind Quillan History of present illness: 47-year-old woman admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Hypotensive despite a 30 mL/kg crystalloid bolus; norepinephrine started. Past medical history: heart failure wi … principal diagnosis A41.9 · encounter ENC-00061
Highest temperature, first 48 h (C)	39.1	temperature 39.1 °C · vital VIT-005961 · 2026-11-09 01:44
Lowest temperature, first 48 h (C)	38.6	temperature 38.6 °C · vital VIT-005953 · 2026-11-08 09:44
Highest heart rate, first 48 h	122.0	heart rate 122/min · vital VIT-005970 · 2026-11-09 17:44
Highest respiratory rate, first 48 h	19.0	respiratory rate 19/min · vital VIT-005924 · 2026-11-08 17:44
Highest WBC, first 48 h (x10^3/uL)	17.81	WBC 17.81 x10^3/uL · lab LAB-002084 · 2026-11-10 05:00
Lowest WBC, first 48 h (x10^3/uL)	14.6	WBC 14.6 x10^3/uL · lab LAB-002080 · 2026-11-08 10:24
Lowest platelets, first 48 h (x10^3/uL)	88.0	platelets 88 x10^3/uL · lab LAB-002085 · 2026-11-10 05:00
Highest bilirubin, first 48 h (mg/dL)	0.43	bilirubin 0.43 mg/dL · lab LAB-002092 · 2026-11-08 10:24
Lowest mean arterial pressure, first 48 h (mmHg)	60.0	MAP 60 mmHg · vital VIT-005959 · 2026-11-08 17:44
Highest norepinephrine-equivalent dose, first 48 h (mcg/kg/min)	0.07	norepinephrine 0.07 mcg/kg/min · med MED-000226 · 2026-11-08 10:24
Lowest Glasgow Coma Scale, first 48 h	15.0	GCS 15 · vital VIT-005956 · 2026-11-08 09:44
Highest creatinine, first 48 h (mg/dL)	0.87	creatinine 0.87 mg/dL · lab LAB-002061 · 2026-11-08 10:24
Baseline creatinine (mg/dL), for the baseline renal SOFA score most recent pre-admission value within 365 days	0.83	creatinine 0.83 mg/dL (pre-admission) · lab LAB-002060 · 2026-07-26 10:05
Highest lactate, first 48 h (mmol/L)	3.78	lactate 3.78 mmol/L · lab LAB-002093 · 2026-11-08 10:24

Rule trace (inputs, thresholds, outcome)

Rule trace (rule sepsis v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
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=39.1, temp_min_48h=38.6	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=122.0, t.hr=90	true
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=19.0, 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=17.81, wbc_min_48h=14.6	true
derived: sirs_count	`count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc)`	sirs_hr=True, sirs_rr=False, sirs_temp=True, sirs_wbc=True	3
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=88.0	2
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=0.43	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=60.0, norepi_max_48h=0.07	3
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=0.87	0
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=0.83	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_cardio=3, sofa_cns=0, sofa_coag=2, sofa_liver=0, sofa_renal=0, sofa_renal_baseline=0, sofa_resp=0	5
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=5, t.sofa_delta=2	true
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=3, t.sirs_min=2	true
derived: shock	`sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false)`	lactate_max_48h=3.78, norepi_max_48h=0.07, sepsis3=True, t.lactate=2	true
outcome: no_infection	`not infection_documented`	infection_documented=True	false
outcome: septic_shock	`shock`	shock=True	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2084); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: infection-related documentation
Encounter: ENC-00061   Patient: Mara Pemberton   To: Dr. Rosalind Quillan

Clinical indicators from the health record:
- Documented in the record: "sepsis" [History and physical DOC-000211]
- "multifocal pneumonia" (2026-11-08 12:24) [History and physical DOC-000211, p. 1, line 5]
- principal diagnosis A41.9 [encounter ENC-00061]
- temperature 39.1 °C (2026-11-09 01:44) [vital VIT-005961]
- temperature 38.6 °C (2026-11-08 09:44) [vital VIT-005953]
- heart rate 122/min (2026-11-09 17:44) [vital VIT-005970]
- respiratory rate 19/min (2026-11-08 17:44) [vital VIT-005924]
- WBC 17.81 x10^3/uL (2026-11-10 05:00) [lab LAB-002084]
- WBC 14.6 x10^3/uL (2026-11-08 10:24) [lab LAB-002080]
- platelets 88 x10^3/uL (2026-11-10 05:00) [lab LAB-002085]
- bilirubin 0.43 mg/dL (2026-11-08 10:24) [lab LAB-002092]
- MAP 60 mmHg (2026-11-08 17:44) [vital VIT-005959]
- norepinephrine 0.07 mcg/kg/min (2026-11-08 10:24) [med MED-000226]
- GCS 15 (2026-11-08 09:44) [vital VIT-005956]
- creatinine 0.87 mg/dL (2026-11-08 10:24) [lab LAB-002061]
- creatinine 0.83 mg/dL (pre-admission) (2026-07-26 10:05) [lab LAB-002060]
- lactate 3.78 mmol/L (2026-11-08 10:24) [lab LAB-002093]

Question:
Based on your clinical judgement and the indicators above, can the documented infection-related diagnosis be further specified?

Response options (select one or write your own):
( ) Sepsis with septic shock
( ) Sepsis (please document the associated organ dysfunction, if any)
( ) Other (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

Hyponatraemia · Clinical judgement required Clinical judgement required: Low sodium without documented treatment or repeat values; clinical significance is a clinician judgement.
Malnutrition · Specificity gap Criteria support Moderate (non-severe) protein-calorie malnutrition (acute illness context) (E44.0); no corresponding diagnosis is documented.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2084	2026-11-14T20:57:24	system:llm system	`llm.call`	ENC-00061, ENC-00061.sepsis	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt e07f51845be9 output 6e7a0dc3aacb entry 1fc41d0d58b0
1258	2026-11-14T19:24:29	system:llm system	`llm.call`	ENC-00061, ENC-00061.sepsis	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt e07f51845be9 output 6e7a0dc3aacb entry e559b6742dad
516	2026-11-14T18:29:04	system:llm system	`llm.call`	ENC-00061, ENC-00061.sepsis	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt e07f51845be9 output 6e7a0dc3aacb entry 59138945f896