Sepsis 2 vs Sepsis 3- what are you doing?
Our facility has received several denials for sepsis, stating that SIRS criteria alone are overly sensitive and inadequately specific for diagnosing sepsis and that there was no evidence of a systemic response to infection beyond that expected with a localized infection.
With the CMS Sep 1 measure in support of Sepsis 2 and literature in support of Sepsis 3, it is challenging for the CDSs as far as clarifying for the diagnosis of sepsis and determining when to send a clinical validation clarification regarding sepsis. Some providers use Sepsis 2 and others use Sepsis 3. There is concern that by using Sepsis 3 criteria we will fall out on the Sep 1 Measure.
How are other organizations and/or CDI programs handling this situation? Has your organization defined sepsis identifying certain criteria in a policy and if so, who developed the policy and does it consist of more than just the definition of sepsis? Do you have a strategy to handle these types of denials? Can payers set clinical criteria and if so, what can organizations do about it if they disagree with the criteria set by the payer?