Denial based on Sepsis 3
We are seeing denials based on Sepsis 3 criteria which we have not adopted as a facility. Just wanting to hear from other facilities who have not yet adopted sepsis 3 and your success with appeals? Any facilities using both Sepsis 1 and Sepsis 3 based on the payer? What about facilities who have already adopted sepsis 3... any tips for transitioning?
LeeAnn
Comments
Difficult topic that can't deserves a lot of attention. When looking at this issue, I personally 'always' and first check the record to see if the patient has any 'acute organ dysfunction' that is associated with Sepsis. If a review of the record indicates organ dysfunction(s) are present that may be a consequence of sepsis, but this is not documented: query. Also, even if the MD did not do so, compute the SOFA score. You may need to issue an 'association' query if a review indicates acute organ dysfunctions are present, but not explicitly linked to Sepsis. Acute organ dysfunction 2/2 Sepsis is SEVERE sepsis and is coded with R65.20.
Paul Evans, RHIA
Do you have a sample of how you write your "association" query?
thanks!
Yes, but I do not know how to drop any files into this new format? Suggest you visit the 'library' and look at the ACDIS tools and I believe we have an example of an 'association query' filed. That should suffice.
off top of my head.
___________________________________________________________________________________
Per H&P, Notes (cite dates), diagnoses recorded include Sepsis and Encephalopathy. Pt admitted with RR of 22, Pulse 109, WBC 20.1 with left shift and abrupt change in mentation. RN records GCS of 5 on day one.
Sepsis alert initiated and patient received Sepsis Bundle. Progress notes document mentation improves with treatment of infection.
Please indicate association, if any, between sepsis and encephalopathy
- Association Exists
- No Association
- Other
- Unable to Determine
__________________________________________________________________________________Again, this is off top of my head, but something like this may suffice. We need the linkage in order to code Severe Sepsis.
Paul Evans, RHIA, CCDS, CCS, CCS-P
Query Topic: Association
An association between diagnoses may not be assumed and must be explicitly documented.
On (DATE) documentation in the (NOTE TYPE) section of the medical record states***
and
on (DATE) documentation in the (NOTE TYPE) section of the medical record states***
CDI: Cite - Evaluation, Monitoring, Treatment, Impact on Medical-Decision Making
Please document the association, if any, between these conditions such as:
Association exists
No association
Cannot be determined