Denials of Sepsis-3 and septicemia
NY state is seeing many denials for Sepsis, based on the new sepsis-3 criteria. I have done a fair amount of research on this topic but have not found anything in the literature that addresses the presence of septicemia and Sepsis-3. Our facility has adopted an unwritten policy stating that if pt. does not meet Sepsis based on SOFA scores, we will not query the provider. However, Here's a scenario that I came across a few times and wonder if we could defend a sepsis diagnosis if it was denied in an audit.
Pt. comes in with Temp 101, HR 125, RR 36, Mean arterial pressures <60, WBC 13.5, and lactic acid 11.7, creatinine 1.03, bilirubin 1.1, plt. 265. E- coli in urine and blood (4 bottles). Pt. clearly meets the definition for sepsis based on Sepsis 2 criteria. However, when looking at Sepsis 3 criteria, only scores1 for MAP < 70. Pt. was not treated with pressors as the patient was not hypotensive and remained alert and oriented. Lactic acid quickly dropped to 4 after IV fluids and antibiotics. Documentation in the H & P states Sepsis but this was dropped from documentation.
Is it appropriate for an insurance company to deny the diagnosis of Sepsis if the patient does not "meet" the definition of Sepsis 3 even if blood cultures are positive in all 4 bottles?
Thanks for your input, Joan
Pt. comes in with Temp 101, HR 125, RR 36, Mean arterial pressures <60, WBC 13.5, and lactic acid 11.7, creatinine 1.03, bilirubin 1.1, plt. 265. E- coli in urine and blood (4 bottles). Pt. clearly meets the definition for sepsis based on Sepsis 2 criteria. However, when looking at Sepsis 3 criteria, only scores1 for MAP < 70. Pt. was not treated with pressors as the patient was not hypotensive and remained alert and oriented. Lactic acid quickly dropped to 4 after IV fluids and antibiotics. Documentation in the H & P states Sepsis but this was dropped from documentation.
Is it appropriate for an insurance company to deny the diagnosis of Sepsis if the patient does not "meet" the definition of Sepsis 3 even if blood cultures are positive in all 4 bottles?
Thanks for your input, Joan
Tagged: