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?
Comments
As an organization we are utilizing Sepsis 2 criteria. Like you we have seen an increase in the denial and recoupments from payers citing the lack of a systemic reaction beyond that expected with an infection. I have seen some of these where they have not only removed the Sepsis but also then removed the infectious process (ex: Pneumonia) which makes no sense.
I have seen suggestions that a facility wide policy surrounding sepsis is something that can aid in appeals. As payers are free to follow whatever criteria they want (and frequently do) I'm not sure what benefit an actual facility policy would play in appeals. My personal belief is the best route is to involve contracting and have an actual criteria placed in the contract.
Many providers document "met SIRS criteria with xxxx and xxxx" (two of four). This alone isn't enough anymore. Education for providers covering what the payers are doing and what documentation they're seeking is an ongoing effort. Queries seeking "systemic dysfunction clarification" (beyond SIRS) along with education will hopefully produce supportive documentation.
Erik Kilbo, CCDS, CDIP, CCS, CPC-I
Manager - Enterprise HIM Coding
Greenville Health System
United Healthcare has opted to adopt Sepsis 3 effective 1/1/2019 which is going to be another payer to fight with their MA plans
https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2018/network-bulletin/October-Interactive-Network-Bulletin-2018.pdf
I am going to boil some water, add paprika, eye of salamander and tail of a crawfish, and ask the Creole Gods of my native town, New Orleans, to provide me some consistent insight into the precise 'criteria' that will satisfy 'everyone'. A lady on Bourbon Street promised me If I perform this rite when the Saints have a home game, I have been assured any advice rendered will be legitimate. This approach seems as defensible as any others?
Happy October...Paul Evans