RAC
Does anyone know when RAC starting using clinical validity to deny Sepsis. I have an appeal with an Admin Law Judge on a case from 2009. Our diagnosis of Endocarditis was downgraded to Sepsis which I understand why due to the coding guidelines. We did not pick up Sepsis. My argument for the Endocarditis is that the patient did not meet Sepsis criteria. I figure if RAC can deny us Sepsis due to clinical validity then we should be able to use the argument also. But if RAC was not using clinical validity to deny Sepsis in 2009, it might be a mute point.
Thanks
Thanks
Comments
I've only been working denials for a couple of years but I inherited cases back to 2011. From what I can tell in the denial letters, RAC's were denying based on Sepsis 2 starting in 2012. The original Surviving Sepsis Campaign was published in 2004 with an update in 2008, 2012 and 2016.
Thankfully, I didn't inherit any cases that were that old.
From Surviving Sepsis 2008 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2249616/
Sepsis is defined as infection plus systemic manifestations of infection (Table (Table11) [12]. Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion. The threshold for this dysfunction has varied somewhat from one severe sepsis research study to another. An example of typical thresholds identification of severe sepsis is shown in Table Table22 [13]. Sepsis induced hypotension is defined as a systolic blood pressure(SBP) of < 90 mm Hg or mean arterial pressure < 70 mm Hg or a SBP decrease > 40 mm Hg or < 2 SD below normal for age in the absence of other causes of hypotension. Septic shock is defined as sepsis induced hypotension persisting despite adequate fluid resuscitation. Sepsis induced tissue hypoperfusion is defined as either septic shock, an elevated lactate or oliguria.
Also found this article that lists the definition of sepsis from 2008
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/intmed/imrp/CURRICULUM/Documents/Surviving Sepsis Guidelines 2008.pdf
Sepsis is defined as infection plus systemic manifestations of infection (Table 1) [12]. Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion.What is interesting is how closely this relates to Sepsis 3.
Hope this is interesting if not helpful!
Cynthia Mead, RN, CCDS LSS-BB
Clinical Documentation Specialist
Flagstaff Medical Center