Denials for sepsis
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?
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