We started using Sepsis 3 criteria shortly after it was released as our payers started using Sepsis 3 as grounds to deny claims.
The biggest piece of advice I can share is to get buy in from your physicians on using Sepsis 3. There is still controversy in the physician community as what criteria best defines sepsis. Add in CMS using Sepsis 2 as the criteria for the quality measure but denying payment if Sepsis 3 isn't met and you have a mess.
One success we have had is to get the majority of our physicians to agree that sepsis is an infection with acute organ dysfunction, regardless of the SOFA score. That is defensible if needed.
I'm happy to try and answer any specific questions you might have on what we have done,
My abbreviated version of advice is to ensure documentation explicitly links any/all organ dysfunctions to infection, if clinically supported. In my view, this must be done in order to code Severe Sepsis, which is now simply 'sepsis' per the Sepsis 3 definition...don't forget the organ functions not mentioned for in Sepsis 3 criteria, such as Type 2 MI, critical illness myopathy.
I'm curious with numerous hospitals using definition Sepsis 2 vs 3 how this will impact data which may be used for aggregate reporting such as PEPPER report. Guess we'll find out:)
We started using Sepsis 3 criteria shortly after it was released as our payers started using Sepsis 3 as grounds to deny claims.
The biggest piece of advice I can share is to get buy in from your physicians on using Sepsis 3. There is still controversy in the physician community as what criteria best defines sepsis. Add in CMS using Sepsis 2 as the criteria for the quality measure but denying payment if Sepsis 3 isn't met and you have a mess.
One success we have had is to get the majority of our physicians to agree that sepsis is an infection with acute organ dysfunction, regardless of the SOFA score. That is defensible if needed.
I'm happy to try and answer any specific questions you might have on what we have done,
Cynthia Mead RN CCDS
Cynthia.mead@nahealth.com
You are talking about Recovery Auditors for MEDICARE billing I assume? (Rhetorical).
I am curious. I may have missed it but has something change since CMS sent a letter to the AMA officially stating they do not support Sepsis 3 and disagree that the criteria of SIRS plus infection are unhelpful?
If recovery auditors are making denials based on Sep 3 then they are in direct violation of the CMS official policy statement on Sep 3 (unless something has indeed changed since this letter was written, see link above.)
My Physician Champion and I presented at the medical Staff meeting a few months ago. I prepared a hand out with SIRS and SOFA criteria and we discussed the barriers of Sepsis 3 due to CMS not adopting it as well as the quality measures, and also discussed the barriers to Sepsis 2 due to commercial insurance denials, etc. We then gave them a few weeks to further research, ask questions, peruse the info,etc. The feedback from several physicians was that we should move forward to Sepsis 3 .We then developed a set of Hospital Guidelines for Sepsis which was presented to the medical staff committees and it was adopted at that time. It is still a work in progress because some of them really have a difficult time wrapping their heads around the changes, and we are a teaching hospital, so it is on-going education, but we are on our way.
Has anyone had success w/ a denial to a commercial payer under the following circumstances:
Medical Record clearly states the following: - Sepsis d/t UTI - SIRS criteria 2/4 - AKI clinical indicators all present - qSOFA criteria clearly met 2/3
EQUIAN denial of appeal due to: "...there is no linkage of an acute organ dysfunction associated w/ the patient's response to infection which is a requirement for validation of sepsis using sepsis 3 definition".
Even though the medical record is complete w/ all diagnosis, complete w/ all clinical validation, complete w/ all treatment. What is not done is stating ..." AKI due Sepsis".
Few questions: 1. Are there any guidelines/rules that commercial payers have to follow in order to deny the case? 2. Now that this denial has occured, can we query the MD for AKI due to Sepsis, 1 year after the patient stay.
Question 1- the challenge with dealing with private payers is they often make their own rules. they can use whatever clinical criteria they wish and often can change the criteria once you learn what they are looking for. Many organizations now are including clinical definitions for known vulnerable diagnoses (such as sepsis) in the contracting process. So that everyone knows from the start what criteria is being used and the rules cannot change during the contract period. I will say from many that I have heard- step one from a commercial/private payer is often to deny and with appeal one can get them overturned. But they are difficult to work with. Question 2- might vary depending upon your organizations contract with the payer and where in the appeals process this case lies.
The information needed for a CDI specialist to be successful is changing every year. Did you ever expect that we would be so involved with the denial process. The best advice I was ever given was to know exactly know what the original contract with the third party payer states, it is harder for them to argue when you are able to use their own words against them.
We try to accomplish all queries prior to final coding. I don't know of a "rule" that says we can't query after final coding but I would not want to place a query a year after discharge.
sbrodie: I know what you mean, I never thought I would be looking at charts for PSI's, HAC's, denials and various quality measures. Our field really does keep growing and changing.
Laurie: I like the idea of including criteria for sepsis (and a few other diagnoses) in our commercial contracts. I have found that the same payer will use different criteria for denying a diagnosis depending on who is reviewing and what criteria best fits their goal, regardless of whether it is the most recent evidence based criteria.
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Hi Quincy,
We started using Sepsis 3 criteria shortly after it was released as our payers started using Sepsis 3 as grounds to deny claims.
The biggest piece of advice I can share is to get buy in from your physicians on using Sepsis 3. There is still controversy in the physician community as what criteria best defines sepsis. Add in CMS using Sepsis 2 as the criteria for the quality measure but denying payment if Sepsis 3 isn't met and you have a mess.
One success we have had is to get the majority of our physicians to agree that sepsis is an infection with acute organ dysfunction, regardless of the SOFA score. That is defensible if needed.
I'm happy to try and answer any specific questions you might have on what we have done,
Cynthia Mead RN CCDS
Cynthia.mead@nahealth.com
You are talking about Recovery Auditors for MEDICARE billing I assume? (Rhetorical).
I am curious. I may have missed it but has something change since CMS sent a letter to the AMA officially stating they do not support Sepsis 3 and disagree that the criteria of SIRS plus infection are unhelpful?
https://jamanetwork.com/journals/jama/article-abstract/2536619?redirect=true
If recovery auditors are making denials based on Sep 3 then they are in direct violation of the CMS official policy statement on Sep 3 (unless something has indeed changed since this letter was written, see link above.)
http://blogs.hcpro.com/acdis/2016/08/news-cms-responds-to-new-sepsis-3-definition/
Hi,
Most of our sepsis denials have been from commercial insurance not the RAC's.
Cynthia
Medical Record clearly states the following:
- Sepsis d/t UTI
- SIRS criteria 2/4
- AKI clinical indicators all present
- qSOFA criteria clearly met 2/3
EQUIAN denial of appeal due to: "...there is no linkage of an acute organ dysfunction associated w/ the patient's response to infection which is a requirement for validation of sepsis using sepsis 3 definition".
Even though the medical record is complete w/ all diagnosis, complete w/ all clinical validation, complete w/ all treatment. What is not done is stating ..." AKI due Sepsis".
Few questions:
1. Are there any guidelines/rules that commercial payers have to follow in order to deny the case?
2. Now that this denial has occured, can we query the MD for AKI due to Sepsis, 1 year after the patient stay.
Question 2- might vary depending upon your organizations contract with the payer and where in the appeals process this case lies.
pjfurey:
We try to accomplish all queries prior to final coding. I don't know of a "rule" that says we can't query after final coding but I would not want to place a query a year after discharge.
sbrodie: I know what you mean, I never thought I would be looking at charts for PSI's, HAC's, denials and various quality measures. Our field really does keep growing and changing.
Laurie: I like the idea of including criteria for sepsis (and a few other diagnoses) in our commercial contracts. I have found that the same payer will use different criteria for denying a diagnosis depending on who is reviewing and what criteria best fits their goal, regardless of whether it is the most recent evidence based criteria.