T. Okafor

Claim CLM-SEP-0177 · 74 M · 4-day LOS · POS 21 · billed charge $39,400

📄 Claim as submitted

Billed DRG

871

Sepsis w/o MV >96h — WITH MCC

Pays

$13,598

A41.9Sepsis, unspecified organismPDX

J96.00Acute respiratory failure, unspecifiedMCC

J18.9Pneumonia, unspecified organismCC

RW 1.9425 × $7,000 base · FY2026 V43.0

🩺 Medical chart

CLM-SEP-0177-seed-record.txtocr complete

74 M with COPD admitted from clinic with 3 days of productive cough, fever, and dyspnea. ED vitals: T 38.6°C, HR 104, BP 96/60 (transiently 88/56, responded to 1 L crystalloid), RR 22, SpO2 93% on 2 L/min nasal cannula. WBC 16.8, lactate 2.4 mmol/L. CXR: right lower lobe consolidation. Diagnosed with community-acquired pneumonia with sepsis. No arterial blood gas was obtained. Oxygen requirement remained 2 L NC throughout the admission and the patient was weaned to room air on day 3. No noninvasive or invasive ventilation. No documentation of respiratory distress, accessory muscle use, or PaO2/PaCO2 abnormality. Hemodynamics: single transient hypotensive episode on arrival, fluid-responsive; no vasopressors administered; repeat lactate 1.6 by hour 8. Started on ceftriaxone and azithromycin. Hospital course: afebrile by day 2, improving oxygenation, discharged day 4. Assessment: CAP with sepsis; hypoxia improved; respiratory status stable on low-flow oxygen.

🤖 Agent analysis

Claude will analyze the medical record against each coded diagnosis using Sepsis-3, ICD-10-CM Official Guidelines, AHA Coding Clinic, and UHDDS reporting criteria — then return a citation-backed disposition.

Rate basis (FY2026 / V43.0): DRG 871 RW 1.9425 (verified CMS); DRG 872 RW 1.0299 (verified CMS FY2024); base $7,000 blended IPPS rate. Validation logic grounded in ICD-10-CM Official Guidelines §I.C.1.d, AHA Coding Clinic, UHDDS, and Sepsis-3 (Singer et al., JAMA 2016). This tool surfaces a recommendation for a human auditor and does not auto-adjudicate.