Guest post: The sepsis criteria dilemma

By Richard Pinson, MD, FACP, CCS

As part of my consulting practice, I do a lot of work on appeals, so the news that United Healthcare plans to start using sepsis-3 criteria for claims review was an important bit of news for me. At the moment, CMS really has not, and does not, endorse specific diagnostic criteria.  Some payers may have specific criteria for some diagnoses. Many leave it to audit contractors who do, but they tend to be arbitrary and unsubstantiated.

On the other hand, the CMS hospital Inpatient Quality Reporting (IQR) program includes a severe sepsis bundle called SEP-1 for which the diagnosis is derived from Sepsis-2 criteria.  CMS has stated it does not plan to change this until more studies of actual clinical outcomes using Sepsis-3 become available. 

However, the Surviving Sepsis Campaign (SSC), which is the authoritative source for the uniform definition and management of sepsis, officially adopted Sepsis-3 in March 2017, so many clinicians have already begun using Sepsis-3. Many disagree and have not accepted it. Personally, I believe SSC should not have adopted Sepsis-3 until outcome data was available. While CMS has not defined sepsis criteria for billing and coding purposes, Sepsis-2 has been endorsed as CMS policy in its IQR SEP-1 bundle, and Medicare contractors/auditors are bound by such policies (though, Medicare Advantage plans may not be). For reference, 2019 CDI Pocket Guide briefly describes the IQR situation in the coding and documentation challenges of its Sepsis-3 key reference topic 

The IQR requirement for quality reporting and public disclosure on CMS’ Hospital Compare website greatly complicates the diagnosis of sepsis for providers. Using Sepsis-2 will capture IQR requirements but isn’t consistent with the authoritative SSC criteria that auditors may legitimately apply and reject the clinical validity of the diagnosis based on Sepsis-2. Appeals are rarely sustainable other than “winging” it with the IQR argument. When a Sepsis-2 based claim is denied, review the record for unrecognized Sepsis-3 indicators as the basis of appeal.

We recommend that providers use the authoritative clinical diagnostic standards of SSC (Sepsis-3) to capture those “severe” sepsis cases bundle while considering if the patient has severe sepsis based on the IQR Sepsis-2 criteria. In either case, the SEP-1 bundle ought to be initiated for clinical and quality purposes since all of those patients may be classified by one or the other as “severe” sepsis 

A long-term solution awaits several years of research exploring the clinical outcomes of applying Sepsis-3 criteria for initiating the SEP-1 severe sepsis bundle.

Editor’s note: Pinson is co-author of the CDI Pocket Guide and the Outpatient CDI Pocket Guide: Focusing on HCCs. He and Cynthia Tang, RHIA, CCS are principals at Pinson and Tang, LLC. Contact him at rpinson@pinsonandtang.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.