If a clinician states that every febrile patient with elevated WBC and antibiotics should be labeled as sepsis, the CDI professional should respond with which statement?

• A. This would be an inappropriate practice.
• B. This is appropriate with justification.
• C. Document sepsis and proceed with treatment.
• D. Seek pharmacist input before querying

Answer: (A)

The main idea being tested is that sepsis labeling must be based on documented criteria rather than assumptions from fever, leukocytosis, or antibiotic use alone. Sepsis is a defined syndrome that reflects a dysregulated host response to infection leading to organ dysfunction or a measurable systemic response. Having a fever and an elevated white blood cell count while receiving antibiotics does not by itself prove that the patient has sepsis. Those findings can occur with many conditions that are not sepsis, and mislabeling can lead to inappropriate treatment decisions, inflated coding, and quality/reporting consequences.

In practice, a CDI professional should look for evidence of systemic impact or organ dysfunction documented in the chart, such as a rise in a SOFA score (or an alternative validated criterion), signs of hypoperfusion, elevated lactate, hypotension, altered mental status, or other organ dysfunction. If such evidence isn’t present, the safer, more accurate approach is to document the underlying infection or febrile illness without sepsis, unless the chart clearly demonstrates sepsis criteria are met. If there is uncertainty, discuss with the care team to obtain and document the specific criteria before assigning a sepsis code.