Documentation of Sepsis, Severe Sepsis and Septic Shock

Posted on Feb 6, 2018 in Announcements | 0 comments

There continue to be missed and mis-diagnoses as well as CDI and coding queries about sepsis –much of this reflects unfamiliarity with the definitions and clinical indicators for sepsis, severe sepsis and septic shock.  For these reasons, it seems like a good time to review this information.  The following examples and comments are based on the current ICD-10 and CMS coding guidelines (which reflect Sepsis-1 and Sepsis-2 definitions).  The Sepsis-3 definitions were initially published in early 2016, but haven’t been adopted by ICD-10 and CMS yet.

Your patient could have SEPSIS if she is ill from a suspected or confirmed infection and has 2 or more SIRS criteria.  If there’s no infection, there’s no sepsis.  And if there’s infection but no SIRS criteria, there’s no sepsis.

The SIRS criteria are:

Temp > 38 C/100.4 F

            < 36 C/ 96.8 F

  HR > 90/min

  RR > 20/min

  WBC > 12k or < 4k or 10% bands

+ if the SIRS criteria can be explained by something else, don’t use them to determine if the patient has sepsis.

++ if the patient has SIRS but no infection, this is non-infectious SIRS (document the cause)

+++ Lactic acidosis is NOT a SIRS criteria

EXAMPLE of IDEAL DOCUMENTATION: “sepsis from UTI (SIRS criteria WBC 15k and temp 101”).

Avoid the term “urosepsis”

ANOTHER EXAMPLE: “non-infectious SIRS due to severe pancreatitis, no sepsis”


SEVERE SEPSIS is currently defined as SEPSIS with acute organ dysfunction that is DUE TO or SECONDARY TO SEPSIS.

A few examples of organ dysfunction:

acute respiratory failure, hypoxic and/or hypercarbic

acute renal failure, AKI, ATN

acute encephalopathy

Lactic acidosis > 2 but less than 4  (AVOID the terms “elevated lactic acid or “elevated lactate”) 


Hepatic failure, shock liver

DIC, thrombocytopenia

AMI, acute coronary synd


MODS multiple organ dysfunction syndrome

+ if the organ dysfunction is due to sepsis, document this association

++ if the lactic acidosis is due to sepsis, document this association

IDEAL DOCUMENTATION: “Severe sepsis from empyema, with DIC due to sepsis”

ANOTHER EXAMPLE: “Severe sepsis—leg cellulitis with SIRS and lactic acidosis due to sepsis”

ANOTHER EXAMPLE: “Severe sepsis—aspiration pneumonia with acute encephalopathy due to sepsis”


If after iv fluid, the patient with SEVERE SEPSIS still has SBP < 90 mmHg or 40 mmHg below baseline and

MAP < 65 OR has persistent lactic acidosis > 4, then document SEPTIC SHOCK.

+ if present, specify other etiologies of shock as well

Beth Gong, MD for the CDI Team /— contact me if questions

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