Tip: Five questions for CDI to consider regarding new sepsis criteria

 

On February 23, the Journal of the American Medical Association published new clinical criteria for sepsis and septic shock. As most of us have probably heard at this point, these new criteria are inconsistent with definitions published in the ICD-10-CM Official Guidelines for Coding and Reporting as well as the Surviving Sepsis Campaign, and confusion about the criteria remains.

 

Should CDI specialists follow these new guidelines, or should they wait for additional clarification from CMS? Following are five questions to consider as your CDI/sepsis task force determines how—or whether—to implement the new criteria in your facility.

 

1. What is the general consensus of your CDI team? Involve your sepsis task force in these conversations. How do physicians feel about these new criteria? What do your physician advisors suggest? Keep in mind that septic shock is an MCC. Everyone must be on the same page regarding coding and documentation practices.

 

2. How will queries change? The new criteria define sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection [suspected or confirmed].” Septic shock is defined as “persisting hypotension requiring vasopressors to maintain MAP [mean arterial pressure] > 65 mmHg and having a serum lactate level > 2 mmol/L despite adequate volume resuscitation.” If you decide to move forward with the new criteria, will you use these terms in place of those that are apparently no longer clinically relevant?

 

3. How will policies and procedures change? Policies must reflect your facility’s decision to use the old, or new, criteria. If you do use the new criteria, be sure to note the date on which these criteria became effective in your facility. Having a clear policy helps your organization defend against claims denials and recoupments.

 

4. How will you provide immediate physician education? Be prepared to get physician champions on board and also solicit support from the facility administration. Without executive support of the new criteria, the credibility of your CDI program is at risk, and physicians may resist the change.

 

5. How will you track sepsis and septic shock-related denials? Monitor these claims very closely as you implement the new criteria. Track claims denials, payer requests for additional information, and recovery audits as they occur for these cases. Use payer feedback and inquiries for educational opportunities. Provide physician support and re-training, as necessary.