As we all know, sepsis denials have escalated since the definition of sepsis was updated back in 2016. The previous definition of sepsis read:
Sepsis is the result of a host’s systemic inflammatory
response syndrome (SIRS) to infection. Severe sepsis
is sepsis with organ dysfunction. Septic shock is severe
sepsis with sepsis-induced hypotension.
The sepsis 3 definition now states:
Sepsis is life-threatening organ dysfunction caused
by a dysregulated host
response to infection.
Septic shock is defined as a subset of sepsis in which
underlying circulatory and cellular metabolism
abnormalities are profound enough to substantially
Let’s look at how this has impacted the healthcare “village”, starting with providers.
If the new criteria are used to evaluate claims for sepsis, then documentation of sepsis alone is not going to be sufficient. Essentially, in order for the new definition to be met, there must be organ dysfunction, which meets the previous definition of severe sepsis. It’s easy to see, then, why there are going to be a large number of denials, if only sepsis is documented and coded. Payers have been quick to jump on the new definition knowing that it presents a disconnect with coding conventions and will result in recoupment for them.
It has been recommended that providers use the Sequential Organ Failure Assessment Score (SOFA score) to assist them in the determination of a sepsis diagnosis. Six different areas are assessed including respiratory, cardiovascular, hepatic, coagulation, renal, and neurological with organ dysfunction determined to exist if there is an increase of 2 points or more in the SOFA score. A quick SOFA score (qSOFA) may be used at the bedside of patients with presumed infection who may require a lengthy ICU stay. This relies on 2 or more of the “HAT” indicators: H=hypotension, A=altered mental status, and T=tachypnea. It is significant to note that under the sepsis 3 definition there is no separate qualification for severe sepsis. The concept was considered redundant in the updated sepsis definition.
It would be prudent for providers to document the clinical indicators that support the sepsis diagnosis including noting any organ dysfunction that is present. If providers can “marry” the diagnoses, for example: AKI and encephalopathy due to sepsis, it provides the necessary context for the sepsis diagnosis and allows coding professionals to capture the appropriate codes.
Clinical documentation improvement specialists (CDIS) are also impacted by the change in the sepsis definition. Their roles are varied. First, they must be front-line educators for the organization’s medical staff. They need to ensure that staff are aware of the clinical definition update and how best to ensure they are capturing the necessary documentation in the patient’s medical record to convey the severity of illness for other providers as well as the coding staff. They act as facilitators between the providers and the coders when documentation is ambiguous by issuing queries meant to clarify the diagnosis to achieve proper code and DRG assignment. They also find themselves on the front lines when responding to reimbursement denials.
Coding professionals are still reeling from the sepsis definition update. While the clinical definition of sepsis evolved, ICD-10-CM coding guidelines and codes did not. That leaves coders trying to make sepsis 3 definitions fit with sepsis 2 codes. Coding professionals have no choice but to work within the parameters of the classification system in place at the time codes are being assigned. However, having said that, coders do need to be aware of the Official Coding Guidelines that relate to sepsis, to ensure that they are applying the guidelines and codes currently in place correctly.
Denials management staff are in the unenviable position of dealing with the avalanche of payer denials that has cascaded as a result of sepsis 3 definition release. They must work with both the coding and CDI staff to determine where the issue is: was there a true coding error on the record, or is the denial a clinical validation problem? Coordination with CDI and coding is critical for rebuttal or rebilling as appropriate. Tracking of the issues and their resolution is important so that information can be disseminated to everyone involved in the process (providers, CDI, coders, contract team, etc.) with areas of improvement noted and education provided to prevent future denials of the same nature.
If the volume of sepsis denials is high, internal auditing by a coding supervisor may need to be performed to determine if the denials are a result of poor coding. Audit results may indicate that the coding issues are pervasive throughout the staff or may show that one or two coders need to have education on the proper coding for sepsis. For either outcome, education will be key to correcting the errors. Following education, another audit should be done to ensure that the concepts taught during education are being employed.
The organization’s team that works on payer contracts has a role in the “village” as well. It may be important during contract negotiations to have language regarding which definition of sepsis the organization’s sepsis claims will be held to by the payer. Getting that spelled out in a contract can be very helpful for all parties involved.
Information technology staff may have the ability within the organization’s EHR to assist with capturing the documentation necessary to validate sepsis and refute denials. If the SOFA or qSOFA scores can be documented within the EHR, that can help support the clinical decision for sepsis and serve as a mechanism to substantiate the diagnosis if a denial is received.
While clearly sepsis is a challenging prospect for organizations, by everyone in the “village” doing their part well, it can reduce the negative impact that organizations are still struggling with today. It may be time to bring your “village” together, engage collaboratively, and deal with sepsis together.
About the Author
She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.