Denials for sepsis

AWARRICK

We've had several denials lately regarding sepsis and clinical validation. The physician advisor has become very strict regarding when we are allowed to query for sepsis. They are trying to say that we can query when they have SOFA criteria or meet Sepsis 3 guidelines. Our hospital works hard to catch sepsis early so hopefully the patient won't reach this level. When I look at my current patients that the MD has already diagnosed sepsis without query, NONE of them have SOFA indicators. Its frustrating when you know a patient is septic but you can't query because they are not sick enough (per MD advisor). Their thinking is if we only include the cases we know without a shadow of a doubt are septic, then no denials. My opinion is that we will miss out on the reimbursement for our treatment that keeps them from getting to Sepsis 3. My managers are looking for something concrete, in writing, that will tell us exactly when to query. They might as well look for a unicorn.  Any thoughts?

lprescott1

I agree with you it is difficult. And everyone is struggling with this. I strongly support SEP 2 definition and use clinical indicators not only of diagnostics, patient presentation but also the patient's treatment plan and monitoring. I think it is also helpful if the provider can add to documentation the fact the sepsis was caught early and the cascade was stopped before further decline.

I also get frustrated when I hear people adjusting their guidelines as related to private payer denials. If we continue to follow that suit the payers will continue to raise the bar knowing we will continue to adjust our standards. We need to use evidence based guidelines to support diagnoses and practice and challenge those who challenge us. if we know the record is vulnerable we should work with the provider to better support the presence of the diagnosis by outlining their treatment plan and their concerns about the patient. And when the treatment plan works- we need to acknowledge that the patient responded and the process was reversed.