Sepsis 3 denial help

chiddink

Hello everyone,

Our 300 bed hospital has started to see denials based on the sepsis 3 definition.  We would appreciate any help with how to navigate overturning sepsis 3 denials.  If your facility has been sucessful please share what worked and why.  A sample of an appeal letter that was sucessful would be wonderful.  Do you use any other tools or resources that you would be willing to share?

Thanks
Cyndy

leeann.rn93@gmail.com

Can you clarify -- Is your facility using Sepsis 3 criteria?    We have not yet transitioned to Sepsis 3 criteria?  Are you seeing this with Medicare only, or commercial insurances as well?

Thanks

morris-jeff@CooperHealth.edu

I don't believe CMS has endorsed Sepsis 3 yet so probably not Medicare. I believe commercial insurances are using it though. 

chiddink

Our facility has not adapted sepsis  3 at this time.

evanspx@sutterhealth.org

I work for a physician that works w/ CMS as they publish and apply various criteria related to various measures.  He  would be keenly interested to review any denials (commercial/CMS/RAC) for sepsis that are based on Sepsis-3 Criteria.  Please consider deletion of HIPAA data and sent th to me at my address:

 evanspx@sutterhealth.org  

He is not promising assistance with clinical review and rebuttals,  but it may  be helpful to our community to provide him w/ samples.

Thank you,

Paul Evans, RHIA, CCDS, CCS, CCS-P

cseluke

Paul, I have received several sepsis denials based on SOFA/Sepsis 3 from Medicare Advantage payers.I will redact and send to you when I get time.

Cathy Seluke 

evanspx@sutterhealth.org

Cathy:  Excellent.  Thank you!

Paul

lauraehrlich@sunstoneconsulting.com

Any thoughts on how to appeal the Sepsis 3 denials from Medicare Advantage payers when the facility has not yet adopted Sepsis 3?  We have one payer who denies almost every sepsis case even when the patient would have qualified for septic shock under the old definitions.  Any help with winning appeals would be greatly appreciated.  

Thanks,
Laura

cseluke

lauraehrlich@sunstoneconsulting.com said:

Any thoughts on how to appeal the Sepsis 3 denials from Medicare Advantage payers when the facility has not yet adopted Sepsis 3?  We have one payer who denies almost every sepsis case even when the patient would have qualified for septic shock under the old definitions.  Any help with winning appeals would be greatly appreciated.  

Thanks,
Laura

Laura-we have gotten a large volume of sepsis denials as well. I have tried many tactics for appeal but have not been at all successful arguing on the basis of SIRS criteria + an infection. I am now trying the tactic of calculating a SOFA score and using an organ dysfunction associated with sepsis. My hospital has not officially adopted SEP 3 criteria either. Makes it very difficult especially when the auditor digs up cases from 2014. I have some appeals out with the SOFA/organ dysfunction defense but have not received determinations yet.

Cathy Seluke

morris-jeff@CooperHealth.edu

The "old cases" should not be under Sep 3. Our Coding Mgr had several of those and wrote a letter citing the date of the 3rd Consensus, etc... and I think she was successful in those.

Can you email me when you get a chance? jwmorris@health.southalabama.edu

Jeff

rwillcutt

Your facility needs a formal position statement approved by Compliance, CMO & Med Exec stating that SEP 3 is not used in your facility.  

proddy@clarionhospital.org

we also have had quite a few denials.  Our facility is on the fence right now, especially with CMS not being on board yet with Sepsis 3 and the quality core measure that is currently in place for Severe Sepsis.  We have been using Sepsis 3 criteria for our commercial payors that are using the Sep 3 criteria and Sepsis 1 criteria for the rest.  In the meantime, I am keeping a log for my physician advisor as to how many cases meet both criteria versus Sep 1 only or Sep 3 only as she was surprised that there would be very many that did not meet both sets of criteria.

evanspx@sutterhealth.org

IMO, it is rather disingenuous for any auditor to attempt to apply any 'new' clinical criteria retrospectively, regardless of whether or not one used SSC criteria versus Sepsis -3.  The reality is that sites used (and some continue to use) SSC in good faith for a number of reasons.  It is simply not fair to go back in time and deny claims based on purported 'lack of clinical' support if or when said proposed criteria did not exist AT THE TIME OF CODING.  In a similar fashion, one could also 'go back in time' and use new and more liberal criteria for ARF and/or MI (KDIGO/Universal Definition of MI) and recode conditions not previously reported citing 'new' medical evidence.  As a corollary, we are required to use and enforce the official coding rules, which do change over time, that are 'in effect' at the time of coding.

Paul Evans, RHIA, CCDS

proddy@clarionhospital.org

so then Paul, it seems like the approach regardless of payor should be the Sepsis/SIRS criteria and not the sepsis 3 until the coding guidelines change, even though some commerical/advantage plans will deny every one of them?

evanspx@sutterhealth.org

It is very complicated - my personal advice in all of this is to 'try to link any acute organ dysfunction' to sepsis as this may provide support for many 'definitions' of sepsis.   Think about this in context and contrast of the definitions of Severe Sepsis (SSC) and Sepsis -3.  We have some great white papers and guidance in our resources tab.  My main point is that no auditor should 'retroactively' deny sepsis based on Sepsis 3 criteria PRIOR to the publication of Sepsis 3.  See comments from Jeff above.

proddy@clarionhospital.org

oh yes I agree with both you and Jeff from that perspective, thanks for clarifying!

hooter1964

Now they are issuing denials with SEPSIS as PDX with LOS < 5 days.. check out 
https://www.icd10monitor.com/news

afrady@hcpro.com

hooter1964 said:

Now they are issuing denials with SEPSIS as PDX with LOS < 5 days.. check out 
https://www.icd10monitor.com/news

To be fair, I don't think Ceasar implied that the literature fully supports (at least no where that I have seen), that sepsis cannot have a rapid resolution (rare but not impossible), just that the documentation in many of the records do not support that the sepsis was actually present in many of those cases.

hooter1964

I agree with Paul on providing additional support in the documentation of Sepsis

General variables

Fever (>38.3 °C) or hypothermia (core temperature <36 °C)

Heart rate > 90 bpm or >2 SD normal value for age

Tachypnea

Altered mental status

Signifi cant edema or positive fl uid balance (>20 ml/kg in 24 h)

Hyperglycemia (plasma glucose >140 mg/dl or 7.7 mmol/l) without diabetes

Inflammatory variables

Leukocytosis (WBC >12,000 cells/microL −1 ) or leukopenia (WBC < cells/microL −1 4,000)

Normal WBC with >10 % immature forms

Plasma C-reactive protein >2 SD above normal value

Plasma procalcitonin >2 SD above normal value

Hemodynamic variables

Arterial hypotension (SBP<89 mmHg, MAP<70 mmHg, or a SBP decrease > 40 mmHg)

Organ dysfunction variables

Arterial hypoxemia (PaO 2 /FiO 2 < 300)

Acute oliguria (urine output <0.5 ml/kg/h for at least 2 h despite adequate fl uid resuscitation)

Creatinine increase >0.5 mg/dl or 44.2 micromol/l

Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)

Ileus (absent bowel sounds)

Thrombocytopenia (PLT < 100,000 microL −1 )

Hyperbilirubinemia (>4 mg/dl or 70 micromol/l)

Tissue perfusion variables

Hyperlactatemia (>1 mmol/l)

Decrease capillary refi ll or mottling

suzanne.swisher@gmail.com

This topic is currently under review by our Med Exec board. Dr. Erica Remer wrote a two-part article on this very conundrum in the ICD10 Monitor. She discusses denial management based on selective criteria, as well as guidance on how to define, document, and code sepsis. She proffers a multiple choice query for the provider to check which best describes the pt's condition using both Sepsi-2 and Sepsis-3 criteria in the query. I found it helpful, and forwarded the article to our corporate steering committee.

https://www.icd10monitor.com/sepsis-then-and-now-how-the-oldest-disease-continues-to-plague-providers-part-ii

jmccorkl@stanfordhealthcare.org

Thanks for this article!  I was just discussing the dilemma of Sepsis criteria with one of our Physician Advisors today.
Jeanne McCorkle BSN, RN, CCDS

leeann.rn93@gmail.com

rwillcutt said:

Your facility needs a formal position statement approved by Compliance, CMO & Med Exec stating that SEP 3 is not used in your facility.  

Do you include this formal position statement when you are appealing the Sepsis 3 denials?  We have not adopted Sep 3 yet and are beginning to see the denials come in.

don.cdi.rn@gmail.com

Look in this year's conference materials for Trey La Charité, MD lecture on auditors ... might find this helpful also in crafting strategy and approaches with external auditors.

The Barbarians at Your Gates: Understanding How Recovery Auditors Work and How to Defend Against Them

Don