Q&A: Reviewing for sepsis
Q: Would anyone be willing to share how their CDI departments are reviewing for sepsis? A while back, my hospital administration went to contracts and requested that I follow up with physicians and staff and start reviewing all commercial insurance and managed Medicare accounts with Sepsis-3 as this was the contractual language as well as the verbiage within the denial letter. All Medicare cases are reviewed for Sepsis-2. Of the three hospitals within my organization, my facility is the only one using this criteria. I have said that we need a Sepsis-2.5 way of reviewing sepsis cases. I have been researching, trying to find some directive on this issue. Is anyone else experiencing or feeling the same? If you are currently using a Sepsis-2.5 process, would you be willing to share some of your thoughts?
Response #1: We don’t review differently by payer. Our clinical staff had a conference several years ago and decided what screening and diagnostic standards they will apply. We review using that standard (though knowing that there will be pushback from certain payers).
Our medical staff chose Sepsis-2, mostly for the utility of early and rapid identification. We generally look for an indicator beyond just the classic systemic inflammatory response syndrome (SIRS) values.
I certainly would not want to have two clinical standards.
Response #2: We use a homegrown Sepsis-2.5 criteria set at our organization.
Basically, we look for at least two SIRS criteria, plus infection or a sequential organ failure assessment (SOFA) score greater than or equal to two, plus evidence of systemic dysfunction and/or organ failure linked to sepsis.
We use clinical validation queries if systemic compromise/organ failure is not documented and linking queries if documented but not linked to the sepsis.
Our current success is that we get documented sepsis without strong clinical evidence ruled out in many records. Our current challenge is that providers confirm the sepsis on the query but do NOT give additional clinical support, so we have to code it knowing it is likely going to be a denial. Education is constantly provided at many levels, but still remains a challenge.
I am curious about your contracts including Sepsis-3 criteria because ours do not specify so payers use whatever they want to deny.
Response #3: Oh, the challenges of managing possible denials with the diagnosis of sepsis! When we (CDI) were notified that two insurance carriers were not following Sepsis-2 and were denying this as a principal diagnosis, we decided to modify our process accordingly. When querying for sepsis as the principal diagnosis, we include all Sepsis-2 criteria (two SIRS criteria, infectious source) as clinical evidence, and we list any Sepsis-3/SOFA evidence, then we calculate a SOFA score and put this in the query. So, all of our sepsis queries have Sepsis-2 and Sepsis-3 data included.
Response #4: Our clinicians use Sepsis-2 criteria to screen, identify, and treat patients for sepsis. This also aligns with current CMS guidelines for sepsis. You are correct that many of our payers have moved to Sepsis-3 for clinical validation denials. In my opinion, as an industry, we need to stand strong and fight back with our appeal efforts. We code by CMS and coding guidelines and not what is dictated by a payer. Our managed care/contracting colleagues also need to support us and not the payer in this space.
Response #5: I absolutely agree that we should not allow payers to dictate clinical criteria. In this case, however, we as a health system have adopted Sepsis-3. Given the Surviving Sepsis guidelines and the CDC endorsing Sepsis-3, I anticipate CMS will fall in line with Sepsis-3 as well. There is a dearth of evidence in support of Sepsis-3 however, so it is a controversial choice depending on the specialty you talk to.
We created a crosswalk for providers to understand the difference, they can still use SIRS, and lactic acid greater than or equal to two to screen for sepsis, but they really need to link organ dysfunction to sepsis. Occasionally, we do see some providers using Sepsis-2 and we clinically validate the diagnosis. We had to do a ton of education through our health system on Sepsis-3. We created smart phrases that prompt the provider to link organ dysfunction with sepsis. We currently use a vendor to do our clinical/coding validation denials and they have mentioned that our sepsis denial volumes are lower compared to other clients.
Response #6: Providers are treating based off the SEP1 bundle and diagnose based off of Sepsis-2 and then commercial insurance payers are denying base off Sepsis-3. It truly is organized crime.
Ultimately, my plan is to write a Sepsis-2.5 policy and take it to administration for approval and use that as a systemwide criteria set for our facilities.
I do review the DRG sepsis denials at my facility and honestly, on the accounts that I have had a query sent on and it was confirmed, I typically agree with the auditor that sepsis doesn’t meet criteria. I am looking at bed placement and treatment as well as clinical presentation and all imaging and lab values. I am looking for the intensity of services and organ dysfunction. I require all my CDI specialists to query for and reach out to our physicians for sepsis with an organ dysfunction link.
It’s a tough one to deal with, but I will keep fighting back where I can.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and was originally published in the Council-only monthly newsletter, the CDI Leadership Insider. For the purposes of this article, all Council member answers have been deidentified.