November 29, 2017

Avoiding Sepsis Denials

I truly love writing appeal letters for insurance denials. It gives me a chance to meld both my medical and writing careers. What’s more, I see it as a “battle of wills” between the provider and insurance company, albeit one fought on keyboard and computer screen. I see what they denied and why, and I then try to craft as best an argument as possible to show why they are full of…ahem…why their argument for denial was misplaced or inappropriate. Typically, I get denials for “lack of pre-authorization” or “lack of medical necessity.” As of late, I have been seeing more and more DRG denials, where the insurance company sends the chart to a third party for validation of the diagnoses being submitted for payments. One that has become a favorite of insurers has been denial of a sepsis diagnosis. This has also been noted by a recent white paper by the Association of Clinical Documentation Improvement Specialists (ACIDS): “Recently, there have been reports of auditor denials for sepsis cases based on the Sepsis-3 definition.”


What’s the Sepsis-3 definition? It is the latest evidence-based definition for sepsis that was published in JAMA in February 2016. For years and years, we have all been taught that sepsis is “SIRS plus known or suspected infection.” This is the definition that CMS, the Center for Medicare and Medicaid Services, also uses. According to the Surviving Sepsis Campaign, however, this definition is no more. Now, sepsis is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” For those of us used to taking care of septic patients, our response was “Umm…Duh.” Yet, the change in definition is not insignificant. In the “olden days,” i.e., 2015, a 65-year-old patient with pyelonephritis, fever of 104, and a WBC count of 23,000 would fulfill the diagnostic criteria for sepsis. Add in a lactate level of 5.0 mmol/L, and it would not be wrong to assign a diagnosis of “septic shock.” Post Sepsis-3, that same patient would not fulfill the diagnostic criteria for sepsis at all. Some payors have learned this and are capitalizing on it by issuing DRG denials for sepsis citing Sepsis-3. To further complicate issues, the ICD-10 CM classification and official CMS coding guidelines have not abandoned the “SIRS plus infection plus organ dysfunction” definition. And CMS’s Hospital Inpatient Quality Reporting measure uses that same definition. Thus, for that very same 65-year-old patient, we need to give a 30 mL/kg bolus, get a repeat lactate, and if they don’t need vasopressors, document a “repeat focused exam” within six hours. Otherwise, we will have quality deficiencies on publicly reported scorecards. “But,” you might say (and be correct), “isn’t it true that, under the new Sepsis-3 definitions, that patient is not septic?” Welcome to American Healthcare in 2017.

Get up off of That…Sofa

To make things further confusing, the new sepsis definitions introduced the SOFA (Sequential Organ Failure Assessment) score. This is not a diagnostic tool for sepsis. Rather, it is a scoring system to grade the severity of organ dysfunction in the setting of infection. It includes parameters for oxygenation, platelet count, Glasgow Coma Scale, bilirubin, degree of hypotension, and serum creatinine level. The worse the organ dysfunction, the higher the SOFA score. The new definition says that, if a patient has known or suspected infection with a change in SOFA score of > 2, they are “septic” and have a higher risk for mortality (it is assumed that a normal, healthy patient has a baseline SOFA score of 0).

Where Do We Go From Here?

From a bedside perspective, we should keep doing what we are doing: aggressively treat a patient whom we suspect is septic with prompt antibiotic therapy and fluids and/or vasopressors if hypotensive. We need a very high index of suspicion all the time. At the same time, as providers who need to be good partners with the hospitals in which we work, we need to be aware of this new Sepsis-3 definition. We need to understand that, in the post Sepsis-3 world, a patient with SIRS and infection but without organ failure cannot be assigned a diagnosis of “sepsis,” even though we may feel in our heart of hearts that they are “septic.” And if we truly feel the patient has sepsis, then we need to clearly document why we feel this patient has a “dysregulated host response to infection.” For example, it is no longer sufficient to document in a history and physical “Sepsis from UTI” if the patient only has a UTI with fever, tachycardia, and an elevated WBC count. This is ripe for denial by payors, who will say that these findings are the normal response to an infection (I have already seen this in denial letters). Rather, we need to document evidence of organ dysfunction – such as hypotension, renal failure, or encephalopathy – as a result of the infection. If we can include a SOFA score, all the better. In fact, in a letter I wrote appealing a sepsis DRG denial, I was able to argue that the patient truly had sepsis because the physician documented a SOFA score in the chart. It all boils down to our documentation: the more solid it is, the less likely we will get denied by insurers, the less likely we will get “clinical queries” by the CDI folks, and the more easily we can get credit for the excellent work we do each and every day. As a Sound Physician Advisor, I can’t read your mind; I can only rely on your documentation. You need to clearly document why you think the patient has what they have and what you are going to do about it. The better you do this, the easier it will be for everyone involved.

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