Querying Sepsis Without Leading
By Robin Sewell, CDIP, CCS, CIC, CPC, CCDS
A chart came across our team recently, causing one of our coders to question whether a query was indicated without being leading. The patient was diagnosed with pneumonia, urinary tract infection (UTI), acute kidney injury (creatinine 2.52), and hypotension (MAP 65). There was an obvious Sepsis-3 query opportunity, but since the provider attributed the AKI and hypotension to dehydration, the coder felt a query could be construed as leading.
“If I query for sepsis now, could that be leading? The provider already gave the etiology.”
That hesitation is one of the most common, yet costly, reflexes in clinical documentation integrity (CDI). It stems from two separate issues. First, a misunderstanding of the current Query Practice Brief. Second, years of “payer conditioning.”
Myth #1: “The provider already answered, so a query would be leading.”
This was the concern that gave our coders pause. And some would argue that this is “introducing a new diagnosis,” as mentioned in the current Query Practice Brief.
What the Brief Says:
“Diagnosis answer options that are not already documented in the health record must be supported by clinical indicators sourced from the medical record. These clinical indicators must be included within the query.”
The clinical indicators were there for sepsis; thus, a query for sepsis would not be introducing a new diagnosis.
The provider’s attribution of hypotension and AKI to dehydration does not close the door. It simply establishes one possible explanation. The purpose of the query is not to overturn that conclusion. It is to reconcile two documented facts that have not yet been connected: an active infection with SOFA-scoreable organ dysfunction and documentation attributing that organ dysfunction to dehydration.
What would make the query leading is the execution:
Playing Doctor: Stating that the AKI and hypotension are organ dysfunction due to sepsis.
Unnatural Selection: Dropping dehydration as an option or presenting only the clinical indicators supporting sepsis while omitting those supporting volume depletion.
Name Dropping: Asking the provider to confirm sepsis rather than clarify the etiology.
Keep dehydration on the table, lay out all the relevant clinical indicators, and ask the provider to clarify what is driving the findings. The provider’s prior documentation is not an obstacle. It is simply one of the possible answers.
Myth #2: “Maybe dehydration really does explain it.”
This is a related myth, and it is largely payer-driven.
The premise is that fluid-responsive hypotension or AKI cannot really represent sepsis. Querying, therefore, becomes chasing a diagnosis that will eventually be denied. This is where payer conditioning has quietly influenced how CDI specialists and coders think.
It is worth going back to the actual Sepsis-3 definition.
Sepsis-3 (Singer et al., JAMA, 2016) defines sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, with organ dysfunction operationalized as an acute increase in the SOFA score of 2 or more points attributable to the infection.
Hypotension drives the cardiovascular component. A MAP below 70 contributes one SOFA point. Creatinine drives the renal component. A creatinine between 2.0 and 3.4 mg/dL contributes two SOFA points. A patient with documented infection, a MAP below 70, and a creatinine of 2.52 already has a SOFA score of 3.
Nothing in the Sepsis-3 definition requires that organ dysfunction persist after a fluid bolus. The familiar “despite adequate fluids” or “in the absence of hypovolemia” language belongs to septic shock, the sickest subset of sepsis, not to sepsis itself.
The real question is attribution. Was the organ dysfunction caused (at least in part) by the infection, or solely dehydration?
In this record, there absolutely was a basis to query. Pneumonia as a source, SOFA-scoreable organ dysfunction, and a competing dehydration explanation created genuine etiologic ambiguity. That is precisely the situation a clinical query is intended to resolve. Uncertainty was not a reason to hold back. It was the reason to ask for clarification.
The Recommended Query:
Clinical indicators in the record:
- ED Vitals: Heart Rate: 91 (Monitored) RR: 23 Blood Pressure: 80/50 SpO2: 94%
- H&P: Pneumonia documented on imaging; UTI + Streptococcus agalactiae
- Labs: Creatinine 2.52 (normal baseline); WBC 14
- Treatment: IV Fluids administered 1.75 liters; Vancomycin/ Zosyn IV ABX
- Progress Note: Pneumonia, UTI, AKI and hypotension documented secondary to dehydration
Query:
The record reflects active infections (pneumonia and UTI), as well as concurrent AKI and hypotension currently attributed to dehydration
Please clarify the etiology of the AKI and hypotension:
- Due to hypovolemia/dehydration
- Due to sepsis secondary to pneumonia
- Due to dehydration and sepsis
- Clinically undetermined
- Other (please specify)
Notice what the query accomplishes:
Any Query Response is a Win!
Regardless of how the provider responds, the record is stronger.
If the provider attributes the findings to sepsis, the diagnosis has been captured through a compliant, non-leading query. If the provider confirms dehydration as the sole etiology, the ambiguity has been resolved, and the documentation is stronger.
Either way, the objective has been achieved. A compliant query is not about obtaining a particular diagnosis. It is about replacing ambiguity with clarity. Clarity is what stands up to audit.
Fewer denials. More defensible queries. Better documentation integrity.
Contact us to lean more about what Query IQ can do for your team.
Clarity isn’t just good practice; it’s denial prevention.
