ACDIS tip: Defend against sepsis denials

by Kelly Sutton, MHL, BSN, RN, CCDS, CCS

According to the 2023 CDI Week Industry Overview Survey, when asked about their top five denied diagnoses, 81.19% of respondents reported sepsis. This is unsurprising, as sepsis is a vulnerable target, in large part due to its clinical criteria.

In 2002, the Society of Critical Care Medicine, the European Society of Intensive Care Medicine, and the International Sepsis Forum launched the Surviving Sepsis Campaign (SSC). In 2004, they published the first guidelines for the management of severe sepsis and septic shock. The first SCC bundles were introduced to assist with the early detection and management of sepsis. Sepsis-2 criteria states that when two or more of the following criteria are attributed to an infectious cause (and cannot be easily explained by another co-existing condition), sepsis is indicated.

General parameters for Sepsis-2 include (Systemic inflammatory response syndrome [SIRS] criteria in bold):

• Temperature > 38°C (100.4°F) or < 36°C (96.8°F)
• Heart rate > 90 beats/minute
• Respiratory rate > 20 breaths/minute or arterial carbon dioxide tension (PaCO₂) < 32 mmHg
• Change in mental status
• Significant edema or positive fluid balance (> 20 mL/kg over 24 hours)
• Hyperglycemia (> 120 mg/dL) in someone without diabetes

Other parameters:

• White blood cell count < 12,000/µL or > 4000/µL or with 10% immature (band) forms
• Elevated C-reactive protein in serum (> 2 standard deviations [SD] above reference value)
• Elevated procalcitonin in serum (> 2 SD above reference value)

• Arterial hypotension (systolic blood pressure < 90 mmHg, mean arterial pressure [MAP] < 70 mmHg, or a systolic blood pressure decrease > 40 mmHg in adults)

• Arterial hypoxemia (partial pressure of oxygen (PaO₂)/fraction of inspired oxygen (FiO₂) < 300)
• Acute oliguria (< 0.5 mL kg/h despite adequate fluid resuscitation for at least 2 hours)
• Creatinine increase ≥ 0.5 mg/dL⁻¹
• Coagulation abnormalities (international normalized ration (INR)> 1.5 or activated partial thromboplastin time > 60 seconds)
• Ileus (absent bowel sounds)
• Thrombocytopenia (platelet count < 100,000 μL⁻¹)
• Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL⁻¹ or 70 mmol/L⁻¹)

• Hyperlactatemia (>3 mmol/L⁻¹); decreased capillary refill or mottling

Severe sepsis is defined within ICD-10-CM as acute organ dysfunction secondary to documented or suspected infection in the setting of sepsis. Septic shock is defined within ICD-10-CM as severe sepsis plus hypotension, not reversed with fluid resuscitation. Other clinical criteria for septic shock includes a use of vasopressors to maintain a MAP > 65 mmHg and a lactate level > 2 mmol/L.

In 2016, a new definition of sepsis and septic shock was introduced when the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) was released. So, what changed? Under this definition, sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to an infection while septic shock is defined as persisting hypotension requiring the administration of vasopressors to maintain the MAP. With Sepsis-3, there are not different definitions of sepsis and severe sepsis.

Clinical criteria for Sepsis-3 utilizes the Sequential (sepsis-related) Organ Failure Assessment commonly referred to as SOFA. It assesses organ function by assigning a grade of 0 to 4 in six body systems. A score of 0 demonstrates no organ dysfunction. Sepsis is defined as a suspected or documented infection and an acute increase of > 2 points from baseline SOFA score. The chart below shows the organ systems in SOFA and the measurements used for the assessment.

However, not everyone agrees on which criteria should be used. Some argue that using Sepsis-2 criteria casts too wide a net and includes patients who likely do not have sepsis. Others argue that using Sepsis-3 criteria may not identify at-risk patients before organ damage is present, causing an increase in mortality.

CMS recognizes the Sepsis-3 guidelines but has not adopted them and currently reimburses based on Sepsis-2 criteria. Some private payers have decided to reimburse based on Sepsis-3 criteria. Hence, it is unsurprising that many CDI professionals have indicated they are receiving sepsis denials. It is not feasible for providers or CDI specialists to look up every patient’s insurance information to determine which criteria their payer is using.

Denials have caused a ripple effect across healthcare organizations, leading to delays in reimbursement and/or uncompensated care. Additionally, extensive labor hours are required to fight denials.

To assist in denial prevention, facilities and health systems should form a multidisciplinary committee to work towards the development of formal, organization wide defined criteria for sepsis. This definition should also be specified in contracts with their payers.

So, what can CDI teams do specifically to mitigate sepsis denials? For starters, clinical validation and DRG validation are important functions that CDI is perfectly poised to perform. Results from the 2023 CDI Week Industry Overview Survey also indicated that 83.17% of respondents in CDI departments assisting with denials were involved in clinical validation denials and 66.34% in DRG validation.

Once an organization agrees on which sepsis criteria they will use, clinical validation becomes an important tool in denial mitigation. The CDI specialist must use critical thinking skills when clinically validating a sepsis diagnosis. For example, if the patient’s record includes documentation of sepsis with one or two heart rate measurements greater than 90 and one respiratory rate greater than 20, even when Sepsis-2 is the preferred criteria, is sepsis a clinically valid diagnosis? Is there an infection? If so, are there signs or indicators that the infection is systemic versus localized? Is the infection being treated? The CDI specialist should send a clinical validation query if there are any questions as to whether the diagnosis is clinically supported.

I’ve had many conversations with CDI professionals who are concerned with the “negative financial impact” of a sepsis clinical validation query. My answer is usually twofold. First, our job is to ensure the accuracy and integrity of the record so that it reflects the patient’s acuity and severity of illness for the episode of care. Second, I focus on the word integrity in clinical documentation integrity. We should never release a claim that doesn’t reflect the patient’s clinical scenario, nor should we expect a payer to reimburse based on an inaccurate clinical summary. If we do, a denial is sure to follow.

Successful DRG validation of sepsis requires knowledge of very specific coding guidance contained in the ICD-10-CM Guidelines for Coding and Reporting and in numerous Coding Clinics. We all know the basic guidelines: For example, when the documentation indicates the admission is for sepsis/severe sepsis caused by a localized infection, sepsis is sequenced first. The localized infection is sequenced as a secondary diagnosis as is severe sepsis and any acute organ dysfunction when present.

However, not all clinical scenarios in DRG validation are so clearcut. Luckily, sequencing guidance is available when sepsis is related to complications, transplants, and devices. Some of the most recent guidance is included in the Coding Clinics summarized below. These should be read in their entirety to ensure the clinical situation is applicable to your patient’s clinical scenario.

• First Quarter 2024, p. 19 indicates that codes T81.42XA, Infection following a procedure, deep incisional surgical site; T81.44XA, Sepsis following a procedure and A41.1, Sepsis due to other specified staphylococcus, should be used for documentation of sepsis due to staphylococcus pyogenes deep operative wound infection, status post CABG.
• First Quarter 2024, p. 20 instructs that both codes T81.43XA, Infection following a procedure, organ, and space surgical site, and K65.1, Peritoneal abscess, are to be assigned for documentation of postoperative intra-abdominal abscess.
• Fourth Quarter 2023, p. 88 indicates thatA41.59, Other Gram-negative sepsis, should be coded as the principal diagnosis for documentation of Klebsiella sepsis (present on admission) without septic shock, due to acute pyelonephritis of a previously transplanted right kidney. Sepsis is the reason for the admission. Codes T86.13, Kidney transplant infection; N10, Acute pyelonephritis; and N16, Renal tubulo-interstitial disorders, are coded as secondary diagnoses. When a transplant complication leads to a systemic infection such as sepsis, sepsis will be sequenced as the principal diagnosis.
• Second Quarter 2022, p. 5 provides guidance for documentation of postpartum sepsis and UTI in a patient with a history of a spontaneous vaginal delivery one week ago. O98.83, Other maternal infectious and parasitic diseases complicating the puerperium, is the principal diagnosis. Secondary codes include A41.9, Sepsis, unspecified organism, since the organism causing the infections was not specified, and O86.20, Urinary tract infection following delivery. O85, Puerperal sepsis, would not be appropriate in this case as it is used to indicate an infection of the genital tract, and this patient had an infection of the urinary tract.
• First Quarter 2022, p. 35 indicates that documentation of sepsis and suspected toxic shock syndrome (TSS) is coded to A48.3, Toxic shock syndrome, as it is considered a systemic infection with inherent shock. A48.3 is more specific than A41.9, Sepsis, unspecified.
• Second Quarter 2020, p. 32 directs us to sequence O86.02, Infection of obstetrical surgical wound, deep incisional site, as the PDX for documentation of sepsis that occurred due to the deep incisional infection of a cesarean wound.  It identifies the site of the infection. O86.04, Sepsis following an obstetrical procedure, would be assigned as a secondary diagnosis.
• Third Quarter 2019, p. 17, instructs that for documentation of sepsis due to catheter associated urinary tract infection (CAUTI), as well as due to community acquired pneumonia due to aspiration, the principal diagnosis should be the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital.
• First Quarter 2019, p. 13 indicates that T82.7XXA, Infection and inflammatory reaction due to other cardiac and vascular devices, implants, and grafts would be coded as the PDX with a secondary diagnosis of A41.59, Other Gram-negative sepsis, for documentation of nosocomial gram-negative bacilli sepsis/blood stream infection, due to a midline catheter. A midline catheter is not a central venous catheter. A code from category T80.21, Infection due to central venous catheter, would not be appropriate in this scenario.
• First Quarter 2019, p. 14 provides guidance for documentation of streptococcal Group B sepsis due to a hemodialysis central venous catheter. The principal diagnosis is T80.211A, Bloodstream infection due to central venous catheter. This code specifies a central venous catheter. A40.1, Sepsis due to streptococcus, group B, is also assigned when a centrally inserted hemodialysis catheter is the cause of sepsis.

In short, to accurately capture sepsis and successfully defend against denials, CDI professionals should have a complete understanding of established organizational criteria and of the coding guidance related to sepsis. This knowledge should be applied in identifying opportunities to obtain the diagnosis when appropriate and to perform clinical validation on every record that specifies sepsis as present. CDI teams should educate providers on sepsis criteria, documentation requirements, and the purpose of clinical validation and clinical validation queries as part of their denial mitigation efforts.

Editor’s note: Sutton is a CDI education specialist at ACDIS/HCPro. Contact her at Kelly.Sutton@hcpro.com.