HIM, Coding and CDI|All facilities (7)
SYNTHETIC DEMO DATA · NO PHIMS-DRG v43 · FY2026
← 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

The chart meets the configured Sepsis-2 clinical screen and contains Sepsis-3 organ dysfunction indicators, but the diagnosis is not carried into inpatient documentation. Recommend a compliant CDI query before assigning A41.9.

Sepsis — Sepsis-2Suspected infection + systemic inflammatory response · Infection + >=2 SIRS indicators + provider documentation
5/6 metInsufficient
  • Met
    Suspected or confirmed infection
    Pneumonia is documented and antimicrobial treatment was initiated.
  • Met
    SIRS: temperature >38C or <36C
    Temperature was 102.4F at presentation.
  • Met
    SIRS: heart rate >90/min
    Heart rate was 118/min at presentation.
  • Met
    SIRS: respiratory rate >20/min or PaCO2 <32 mm Hg
    Respiratory rate was 24/min at presentation.
  • Met
    SIRS: WBC >12,000, <4,000, or >10% bands
    WBC was 17.2 at presentation.
  • Insufficient
    Provider documentation of sepsis diagnosis
    ED concern is documented, but the inpatient assessment does not carry sepsis forward.
Sepsis — Sepsis-3Suspected 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 indicators meet the configured Sepsis-2 screen and suggest Sepsis-3 organ dysfunction, 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)