Q&A: Denials for septic shock

Q: We have a couple providers that will diagnose patients with severe sepsis with septic shock when they are hypotensive stating that they “caught the cascade early” and averted the need for vasopressors. Alternatively, the physician may consider the patient to be in shock, but there’s another reason they want to avoid vasopressors (such as a cardiac conditions), and they’re giving the patient a chance to improve on fluids only, or the patient is getting other volume expanders like albumin or blood. Any ideas how we can fight (or even prevent) these denials when vasopressors weren’t used?

A: It sounds like the payer may be using sepsis-3 criteria as a basis for denial as that set of criteria says that vasopressors must be administered in order for the patient to be in septic shock. The short easy answer to avoid denials, of course, is just to use whatever criteria the payer says, but I do not think that course of action ultimately maintains quality care into the future.

All patients are different, and they may not neatly fit into a criteria box. Let’s consider a younger patient with effective cardiac compensatory mechanisms. A patient in septic shock at the cellular level can respond in a couple ways. You have three baro-receptors: two in each carotid artery and one in the aorta. Using the autonomic nervous system, a generally healthy patient can respond by increasing the systemic vascular resistance via clamping down on peripheral circulation (although you might observe this with cold clammy extremities).

The autonomic nervous system then stimulates both cardiac rate and contractility (and you would be able to observe this via tachycardia and some patients might even complain of a “heart pounding”). Such a patient can present normotensive and still be in septic shock. For this reason, I personally have not bought into the sepsis-3 definition of septic shock, save one point: If you look closely, there are more criteria for septic shock in sepsis-3 than just the use of vasopressor to maintain a MAP >65. According to the sepsis-3 definition:

Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.

Note the “or” in “or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.” This is especially helpful in identifying patients with positive cardiac compensatory mechanisms that would be otherwise missed using blood pressure (BP) alone.

Also, keep in mind the baseline leveling. My wife barely reads a 90/50 on a healthy day, so a BP of 87/45 may not be especially concerning.

My BP (when not on medication), however, can be as high as 170/100, so even at 110/60 (if it was a sudden drop like shock), I may be experiencing dizziness, weakness, syncope, and hypoperfusion to my kidneys (at least until my set points get re-leveled and the BP brought down slowly). I find the setting of a “one size fits all” single value cut off to be easily applied in theory, yet extremely inaccurate when considering the actual presentations of real patients in the real world. 

As stated above, if your facility does or does not recognize sepsis-3, that needs to be in an official policy somewhere. If this is a private payer, the contract should be looked at to see if it allows the payer to select sepsis-3 criteria and enforce it on their claims for their insured patient population and if there is any language in the contract that allows the facility to object to the insurance position on enforcing a certain criteria for payment purposes and what the facility can do about it, if anything. 

James Kennedy, MD, CCS, CDIP, CCDS, pointed out that one COULD go down the rabbit hole on compliance concerns. ICD-10 guidelines are a part of HIPAA and those guidelines state that reporting is based on provider documentation and the clinical circumstances encountered by the treating provider in the room with a patient, not arbitrarily restrictive definitions which may not clinically be best suited to a particular patient. Neither the Official Guidelines for Coding and Reporting, nor ICD-10 itself, nor CMS, nor Coding Clinic officially recognize sepsis-3. The Surviving Sepsis Campaign has recognized the sepsis-3 revised definition that sepsis involves a dysregulated host response to an infection which leads to organ dysfunction, but they haven’t gone much farther than that. We still have no consensus on how “dysfunction” is defined.

The Sequential Organ Failure Assessment (SOFA) table involves scoring at levels that are clearly not defined as failure, which is completely out of sync with classic reporting and coding. Traditional coding auditors may still be expecting to find diagnoses of organ failures on records (with R65 category codes for severe sepsis) and not find any if the SOFA table was used rather than a more restrictive tissue-based definition of true organ failure. The overly restrictive definition issue has now crossed over into defining what shock looks like in a septic patient as well. Do we only report patients at the extreme end of the continuum and who are at near death? Or, do we also report the early cases where the treatment works and catastrophe in the form of the need for vasopressors is averted if we have OTHER valid clinical evidence of shock outside of hemodynamic decompensation?

As Cesar M. Limjoco, MD, recently pointed out, the entire reason why we change our criteria (some times more aggressive, some times more conservative) is because we learn more about diseases processes and strive to treat them better. It is inappropriate for a payer to pigeonhole the hospital into using their “pet criteria” given the number of patient presentations and the complexity of each patient's bio physiology which is not a uniform standard that is applicable across the board for metrics in a world where you also have multiple confounding criteria and standards of which no single one has been proven above the rest.

If there were valid reasons why vasopressor therapy was withheld in the presence of septic shock such as cardiac risks, that should be documented very clearly in the record. If alternative therapy such as volume expansion were used effectively as a rescue agent for septic shock, you may face a bit of controversy, so I would recommend you request the physicians document their FULL rationale in the record. One to three sentences further explaining the situation can go a long way.

As far as best practice goes, you should be aware that this will likely not stop the denials from being generated. Denials for shock when there is a lack of vasopressor use and denials for sepsis when SOFA isn’t demonstrated in the record are likely here to stay. The only real fix until the next criteria comes out is likely to require a legal or contractual maneuver. For this reason, many physician advisors have been advocating that sepsis be documented both in terms of the SOFA table while still acknowledging all other organ dysfunctions (there are only six in SOFA) while also documenting systemic inflammatory response syndrome (SIRS).

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, click here.