Denial for PDX of sepsis

jennwalts

 I recently had a denial for the diagnosis of sepsis because it was not treated. The patient came in to the hospital with a pneumoperitoneum and was clearly septic. The patient was treated in the ED with IV antibiotics, Fluids and was switched to comfort care prior to the admission. The insurance company is denying the sepsis diagnosis as it was not treated even though patient had AMS, Tachycardia, an elevated lactate (4.1), and hypotension. The patient expired within 24 hours of admission.  I responded to the denial quoting the principal dx definition from the official coding guidelines, and explaining that sepsis was treated in the ED and that patient was switched to comfort care prior to her admission. I also included that the patient expired and the cause of death was listed as sepsis. Has anyone had similar denials? If so how did you fight them?

afrady@blr.com

I will quote myself:  "I never query for Sepsis which was untreated...the one exception being when they are immediately made hospice, which then explains the lack of treatment".

I think what you are experiencing is just ..."payers being payers".  They like to be difficult and not apply much common sense to their rationale.

evanspx@sutterhealth.org

Agree 100% w/ Allen.   As the record documents the decision for Comfort Care, there is a clearly stated rationale as to why the condition was not treated.   The basis for the denial is not supported based on the description you provided.  

As one additional example:  A 50 y/o is admitted with massive ICH causing vasogenic edema and hernia of the brain.   Medical staff determines treatment is futile and places on Comfort Care - no ICP, no sodium goals, no steroids - simply treat for Comfort.   The fact the ICH caused the hernia and edema is relative for Medical Management of the patient and are factors in decision to place on Comfort Case, making them clearly reportable, even though not treated.

Paul Evans, RHIA, CCDS

evanspx@sutterhealth.org

Also, assuming the sepsis is clearly stated, and that the denial is solely based on the decision not to treat, the denial seems disingenuous given all should comprehend that reversal of the condition was not the desired goal for this case.  I’d cite in my communication to the 3rd party the ‘intent’ and ‘purpose’ of Comfort Care given this explains the reason no treatment was rendered.

evanspx@sutterhealth.org

I meant ‘parsamonious’ in an intellectual fashion, but also fiscally!  Maybe Draconian is a better choice.  But, seriously,  some 3rd parties seem at least obtuse and unreasonable?  We all want to do the ‘right thing’ and work compliantly.