KPC Health Chart Screener AI Demo

← Work Queue|TRAN, BAO67MMRN 9000021355 · Acct 402000030702 · Orange County GMCAdmit 07/12/2026 · Disch 07/16/2026

In Review

Okafor, Daniel MD (Emergency Medicine) · 07/12/2026 03:41

67-year-old male presents with productive cough, fever, and confusion per spouse. VITALS: Temp 102.4F, HR 118, RR 24, BP 92/58, SpO2 89% on room air. LABS: WBC 17.2, lactate 3.1 mmol/L, creatinine 1.4 (baseline 1.0). IMAGING: CXR shows right lower lobe consolidation consistent with pneumonia. MDM: Concern for sepsis secondary to community-acquired pneumonia. Sepsis bundle initiated: blood cultures x2, broad-spectrum antibiotics, 30 mL/kg crystalloid bolus. Admitted to medicine.

AI screening summary

Sepsis-3 elements are clinically present at presentation but the diagnosis is not carried into inpatient documentation. Recommend a compliant CDI query to the attending before assigning A41.9.

Sepsis (Sepsis-3)Suspected infection + SOFA increase >=2 · Both elements plus explicit provider diagnosis

2/3 metInsufficient

Met
Suspected or confirmed infection
CAP confirmed on imaging; cultures and antibiotics initiated.
Met
Organ dysfunction (SOFA increase >=2)
Hypotension, hypoxia, elevated lactate, and acute encephalopathy at presentation.
Insufficient
Provider documentation of sepsis diagnosis
ED note documents concern for sepsis; inpatient H&P does not carry the diagnosis forward.

Code suggestionsCoder decision required on every line

A41.9PrincipalNEWSepsis, unspecified organismconf 62%

Clinical picture meets Sepsis-3 at presentation, but the inpatient provider has not documented sepsis as a diagnosis. A compliant CDI query is recommended before coding.

J18.1PrincipalLobar pneumonia, unspecified organismconf 90%

Documented CAP with RLL consolidation. Current principal diagnosis as coded.

G93.41MCCNEWMetabolic encephalopathyconf 58%

H&P documents acute encephalopathy attributed to infection. Specificity query recommended (metabolic vs other).

Suggested CDI query draft

Dr. Shah: The ED note documents concern for sepsis with lactate 3.1, hypotension (92/58), and encephalopathy, and a sepsis bundle was initiated. In your clinical judgment, was sepsis present on admission, ruled out, or unable to be determined? Please document accordingly.

DRG and estimated reimbursement (Medicare inpatient)

As coded

DRG 194wt 0.8480

Simple pneumonia and pleurisy with CC

$5,163.88

With A41.9 (if accepted)

DRG 872wt 1.0687

Septicemia or severe sepsis without MV >96 hours without MCC

$6,507.83

Potential reimbursement delta+$1,343.95

Payment = DRG weight x blended base rate ($6,089.48)