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-00092
Pilar Kestrel: Sepsis
ENC-00092 · 78M · Hospital Medicine · admitted Sat Oct 31, 2026 11:04 AM · discharged Sat Nov 07, 2026 11:56 AM · attending Dr. Cyrus Ellingham
Clinical judgement required Clinical judgement required Open
Contested definitions (Sepsis-2 vs Sepsis-3)
Clinical judgement required: Definition-dependent: 3 SIRS criteria (Sepsis-2 met) but SOFA change only 0 (Sepsis-3 not met).
Documented vs supported
- Documented
- “sepsis” · A41.9 Sepsis, unspecified organism
- Criteria support
- no conclusion: clinical judgement required
- Outcome
- Definition-dependent: 3 SIRS criteria (Sepsis-2 met) but SOFA change only 0 (Sepsis-3 not met)
- 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.
Clinical judgement required. The rule does not conclude here. A CDI specialist may send an open query or dismiss the finding; nothing is proposed as fact.
Effect if the clinician agrees (illustrative)
- Change
- no projected change (clinician judgement)
- Secondary-diagnosis level
- principal → —
- MS-DRG (illustrative)
- 871 Septicemia or severe sepsis without MV >96 hours with MCC → 871 Septicemia or severe sepsis without MV >96 hours with MCC
- Relative weight
- 1.9425 → 1.9425 (+0.0000)
- Codes before
- A41.9, J18.9, E66.813, E11.9, E78.5
- Codes after
- A41.9, J18.9, E66.813, E11.9, E78.5
All open gaps on this encounter together: MS-DRG 871 → 871 (RW +0.0000). The grouping does not change; the record becomes accurate.
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.
| Input | Value | Source |
|---|---|---|
| Infection quoted from a note or an infection principal diagnosis | True |
“left lower lobe pneumonia”
Show the quote in the note… 26-10-31 11:04
Service: Hospital Medicine Attending: Dr. Cyrus Ellingham
History of present illness: 78-year-old man admitted with sepsis. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: type 2 diabetes, hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: clear …
principal diagnosis A41.9
|
| Highest temperature, first 48 h (C) | 39.2 |
temperature 39.2 °C
|
| Lowest temperature, first 48 h (C) | 38.7 |
temperature 38.7 °C
|
| Highest heart rate, first 48 h | 121.0 |
heart rate 121/min
|
| Highest respiratory rate, first 48 h | 18.0 |
respiratory rate 18/min
|
| Highest WBC, first 48 h (x10^3/uL) | 18.6 |
WBC 18.6 x10^3/uL
|
| Lowest WBC, first 48 h (x10^3/uL) | 15.08 |
WBC 15.08 x10^3/uL
|
| Lowest platelets, first 48 h (x10^3/uL) | 225.0 |
platelets 225 x10^3/uL
|
| Highest bilirubin, first 48 h (mg/dL) | 0.76 |
bilirubin 0.76 mg/dL
|
| Lowest mean arterial pressure, first 48 h (mmHg) | 81.0 |
MAP 81 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) | 2.65 |
creatinine 2.65 mg/dL
|
| Baseline creatinine (mg/dL), for the baseline renal SOFA score most recent pre-admission value within 365 days |
2.54 |
creatinine 2.54 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=39.2, temp_min_48h=38.7 | true |
| derived: sirs_hr | coalesce(hr_max_48h > t.hr, false) |
hr_max_48h=121.0, 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=18.0, 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=18.6, wbc_min_48h=15.08 | 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=225.0 | 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=0.76 | 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=81.0, 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=2.65 | 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=2.54 | 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=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=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=True, sepsis3=False | false |
| outcome: sepsis3_only | sepsis3 |
sepsis3=False | false |
| outcome: definitions_disagree | sepsis2 |
sepsis2=True | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2147); 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-00092 Patient: Pilar Kestrel To: Dr. Cyrus Ellingham Clinical indicators from the health record: - Documented in the record: "sepsis" [History and physical DOC-000313] - "left lower lobe pneumonia" (2026-10-31 14:04) [History and physical DOC-000313, p. 1, line 5] - principal diagnosis A41.9 [encounter ENC-00092] - temperature 39.2 °C (2026-11-01 11:24) [vital VIT-009037] - temperature 38.7 °C (2026-11-01 19:24) [vital VIT-009041] - heart rate 121/min (2026-11-01 19:24) [vital VIT-009042] - respiratory rate 18/min (2026-10-31 11:24) [vital VIT-008982] - WBC 18.6 x10^3/uL (2026-11-02 05:00) [lab LAB-003146] - WBC 15.08 x10^3/uL (2026-10-31 12:04) [lab LAB-003142] - platelets 225 x10^3/uL (2026-11-01 05:00) [lab LAB-003145] - bilirubin 0.76 mg/dL (2026-10-31 12:04) [lab LAB-003158] - MAP 81 mmHg (2026-10-31 19:24) [vital VIT-009031] - GCS 15 (2026-10-31 11:24) [vital VIT-009028] - creatinine 2.65 mg/dL (2026-10-31 12:04) [lab LAB-003118] - creatinine 2.54 mg/dL (pre-admission) (2026-09-20 10:05) [lab LAB-003117] Question: Could you review the indicators above and clarify the status of the documented infection-related diagnosis? Response options (select one or write your own): ( ) 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
- Chronic kidney disease · Specificity gap Criteria support Chronic kidney disease stage 4 (N18.4); no corresponding diagnosis is documented.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2147 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00092, ENC-00092.sepsis | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 4fe3158ae3fe output aa58f88e62fe entry 99fb476c7869 |
| 1321 | 2026-11-14T19:24:30 | system:llm system |
llm.call |
ENC-00092, ENC-00092.sepsis | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 4fe3158ae3fe output aa58f88e62fe entry 34f3504e6708 |
| 579 | 2026-11-14T18:29:05 | system:llm system |
llm.call |
ENC-00092, ENC-00092.sepsis | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 4fe3158ae3fe output aa58f88e62fe entry 832cc44600ea |