Reasons for Denials and Prevention | Sepsis Series

Why are so many sepsis records denied?

It’s hard to say why there seem to be so many sepsis denials of late, but most likely this is due to the multiple sets of criteria for the diagnosis of sepsis, change in definition of sepsis, as well as physician documentation. Below are a few definitions to help explain what some of the denial examples are referring to:

• Sepsis 1 definition—Systemic Inflammatory Response Syndrome (SIRS) plus known or suspected infection
• Sepsis 2 definition—2 SIRS criteria plus known or suspected infection
• Sepsis 3 definition—a life-threatening organ dysfunction due to dysregulated host response to infection (2 points or more in the Sequential Organ Failure Assessment [SOFA] score)
• SOFA score—is a mortality prediction score that is based on the degree of dysfunction of six organ systems. This is used to track a person’s status during the stay in the ICU and helps to determine the extent of organ function or rate of failure

Insurance companies use different criteria (as above) since there is no specific one that is mandated to follow. This does make it difficult for coders and facilities. Coders, CDI and physicians should be aware of any specific coding and documentation guidelines that have been agreed upon in a contract with an insurance company or payer. Some of these will specify which sepsis definition needs to be followed for patients that they are providing coverage to. This is evident by some of the denial reasons that are below. Coding and/or Health Information Management (HIM) should be involved and aware of anything in a contract in regards to coding and documentation requirement of health care records. The language used in contracts for some payers on reporting the diagnosis of sepsis is very relevant to being able to appeal a denial.

Are sepsis denials the coders’ fault? Not usually! The majority of sepsis denials are clinical denials. Clinical denial audits are where the payer is questioning whether or not the physician’s diagnosis of sepsis is clinically supported.

Examples of denial reasons:

• “Lack of clinical indicators documented in the medical record”
• “All septic patients are infected however not all infected patients are septic. Without some evidence of impaired homeostasis beyond what the SIRS criteria alone define, sepsis should not be diagnosed”
• “The clinical indicators within the medical record can be explained by the localized infection and do not justify a diagnosis of sepsis”
• “Without some evidence of impaired homeostasis, sepsis should not be diagnosed. These include altered mental status from baseline, hyperglycemia, hypotension, oliguria, coagulopathy, thrombocytopenia, ileus, acute hepatic failure, elevated lactate and capillary mottling”
• “Documentation does not support the diagnosis of sepsis as defined by the “SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference” (sepsis 2).”
• “The patient was not described as toxic in appearance and objective clinical data did not support a diagnosis of sepsis. The treatment plan was appropriate to treat a localized infection and did not reflect the greater levels of monitoring and intervention required to treat sepsis.”
• “The diagnosis is acknowledged to be in the medical record from the physician but don’t think this was a valid diagnosis”
• “There was no positive blood culture, no hypotension, no ARDS, no capillary mottling, no liver failure, no oliguria, no thrombocytopenia and no ileus. Without some evidence of impaired homeostasis beyond that which the SIRS criteria define, sepsis should not be diagnosed.”
• “There were no physician documented signs or symptoms that would have been consistent with a sepsis diagnosis. While there was leukocytosis and fever, there were no other laboratory findings to support SOFA indicators, which assists to clarify and define the diagnosis of sepsis.”
• “The clinical evidence in the medical record did not support the assignment of sepsis. It was noted the physician documented sepsis in the discharge summary. Though the patient was noted to have white blood cell count of 17.6 and a temperature of 102.8F, these findings are to be expected with any infection. There was insufficient clinical evidence and supportive documentation in the record available for review to substantiate the coding of sepsis.”
• “While sepsis is documented in the medical record, there is no clinical evidence found to support SOFA criteria. “
• “Although we agree that the physician documented sepsis in the provided medical record, we do not agree that two or more SIRS criteria clinically support a diagnosis of sepsis.”

How can coders help prevent sepsis denials?

As you can see in the examples above, the majority of the denials are due to lacking documentation or clinical indicators in the medical record. Remember, even if coded based on the physician documentation, if there’s no clinical indicators present to support the diagnosis, there is a high chance of denials. When this occurs, it impacts the entire facility. Denials are expensive. Payment must be returned and/or not received. The facility must spend time to review the records that are denied and all this just adds up.

What can coders do to help prevent sepsis denials?

• Educate providers and CDI on what is needed in the documentation such as a good H&P to capture the severity of illness and also the presenting signs and symptoms; a detailed summary of the findings during the workup; and a DS that describes  the hospital course and treatment necessary.
• The clinical signs and symptoms and other indicators should be linked to the diagnosis of sepsis if that is what they are due to and not to the localized infection
• Documentation should be consistent and complete…if not, a query should be sent for clarification
• Collaboration between coders, CDI and physicians to ensure that the documentation clearly describes the condition of sepsis
• Facilities should have an escalation policy for CDI and/or coders to send records that lack clinical support of sepsis prior to finalizing the record
• Coders, CDI and physicians should be aware of the different sepsis criteria used
• If there are contracts with certain payers on what criteria will be used, coders, CDI and the physicians should be aware of this. If they are not aware then there may surely be lacking documentation in the records
• QUERY at the time of coding prior to billing
• Never depend on the denial letter to list all the clinical indicators. ALWAYS review the record to be sure that there are no other clinical findings to help support the diagnosis that was reported. Oftentimes only a superficial or minimal review of the record may lead to a claim denial.
• Consider having a second-level review to determine if there is clinical validity within the record to support the diagnosis of sepsis before billing
• Appeal letters should include ALL of the supporting documentation in the record for sepsis and any references that help to support reporting this diagnosis
• When writing an appeal letter be sure and state that you realize that there are differences of opinion

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

Remember, even if coded based on the physician documentation, if there are no clinical indicators present to support the diagnosis, there is a high chance of denials. When this occurs, it impacts the entire facility.

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References
https://assets.hcca-info.org/Portals/0/PDFs/Resources/Rpt_Medicare/2017/rmc052217.pdf?ver=2017-05-19-103818-393
https://soundphysicians.com/blog/2017/11/29/avoiding-sepsis-denials/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2703722/
https://www.acponline.org/system/files/documents/about_acp/chapters/mn/18mtg/pendleton_1.pdf
https://rebelem.com/episode-37-definitions-identification-sepsis-sepsis-2-0-vs-sepsis-3-0/
https://journals.lww.com/shockjournal/FullText/2017/09000/Comparison_of_the_Performance_Between_Sepsis_1_and.5.aspx#O15-5

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.