Guest post: Sepsis criteria headaches

CDI Blog - Volume 11, Issue 242

Howard Rodenberg,

By Howard Rodenberg, MD, MPH, CCDS

By now, I’m certain that Zephyrus hath inspired in every holt and heath the news that UnitedHealthcare has adopted Sepsis-3 as their gold standard for the diagnosis of sepsis. Most CDI folks knew this was coming. There have been any number of articles and lectures about the need to adapt to Sepsis-3, and those of us involved in the denials process have heard this argument mounted against our claims. It’s just that UnitedHealthcare is the first to publically draw a line in the sand.

But is anyone within the CDI community still advocating for Sepsis-2? The answer is yes. Specifically me, and in the next few paragraphs I hope to show you why.

The place to start is by understanding the nature of Sepsis-2 and Sepsis-3. Neither of these are clinical entities unto themselves, but labels for a constellation of signs that, taken together, define clinical sepsis. The disease itself hasn’t changed, merely the description of a host response to infection.

Sepsis-2 (published in 2001) characterizes sepsis as the presence of systemic inflammatory response syndrome (SIRS) parameters such as changes in pulse, white cell count, temperature, or respirations in the presence of infection. Sepsis-3 (published in 2016) is the newest iteration of that definition, and it is much more restrictive, requiring the confirmation of certain laboratory values and calculation of a sequential organ failure assessment (SOFA) score to determine the diagnosis.

Whereas Sepsis-2 has been well accepted since its debut, the same cannot be said of Sepsis-3. Some medical groups, such as the Society for Critical Care Medicine (SCCM) and the American College of Chest Physicians (ACCP), have endorsed it; many others, including key players such as the Infectious Disease Society of America (ISDA) and the American College of Emergency Physicians (ACEP), have not. Importantly, the CMS does not endorse the new definitions and has no plans to do so. A review of the literature shows multiple publications offering critique of Sepsis-3, even from professionals within organizations that have endorsed the guidelines. Clearly, clinical acceptance of Sepsis-3 as the standard of care is far from a done deal.

There are a wide range of criticisms of Sepsis-3 from the clinical side, but the most critical point is that when the more restrictive Sepsis-3 criteria are used to define the condition, mortality rates rise. Preventing death from sepsis is directly linked to early intervention. Withholding a diagnosis until the Sepsis-3 parameters are met may delay appropriate care, resulting in increased deaths. Medicine intentionally uses over-triage as a way to prevent morbidity and mortality; restricting the over-triage inherent within the broader definition of Sepsis-2 undermines this goal. This is expressively the reason why CMS will not endorse Sepsis-3.

It’s worth noting that the insurance companies would say that rises in mortality using the new definition are not cause-and-effect; it’s not that Sepsis-3 causes a higher mortality rate, but that as sepsis is a life-threatening condition a more specific definition would necessarily reflect a higher lethality. That may be true, but clinically no one is going to wait for a patient to get to the point of increasing mortality before starting aggressive care. The result is that the care patients receive to prevent them from getting to that point becomes uncompensated in a perverse version of the unfunded mandate.

Patient care concerns always come first. But we would be remiss in our defense of Sepsis-2 without addressing the quality and fiscal implications of a change in definition. Under the Sepsis-3 definition, quality measures will necessarily report a higher mortality rate for sepsis. This can result in not only poor ratings on publicly-reported measures (such as Hospital Compare), but also significant financial loss when quality metrics are factored into reimbursement from third-party payers.

From a coding standpoint, not much changes. Whatever paradigm the physician uses to diagnose sepsis, once that’s on the chart we are obliged by certain conventions (the Official Guidelines for Coding and Reporting and Coding Clinics) to code the condition. In addition, we would adapt our queries to ask about sepsis only when the new parameters (Sepsis-3) were met, but the diagnosis was not recorded by the attending physician. However, a shift to a Sepsis-3 definition with its more restrictive criteria significantly reduces the number of sepsis cases reported within a hospital. A tighter definition means fewer cases reported, and fewer claims generated on behalf of that diagnosis. The total revenue derived from cases where sepsis is documented is certain to fall.

We’ve actually done some in-house research at my facility that shows a shift to Sepsis-3 would decrease the number of sepsis cases to be coded by almost two-thirds, with a resultant loss of revenue, especially from groups such as CMS which continue to reimburse sepsis based on the broader definitions (Sepsis-2). If we continue to use Sepsis-2 as our basis for physician education and coding, we will undoubtedly get denials from third-party agents. However, I would much rather defend a definition that promotes timely, aggressive, lifesaving care at appeal rather than concede to an imposed definition that puts patients at risk. As a clinician, standing up for those physicians using Sepsis-2 to guide early and aggressive patient care as simply the right thing to do.

It’s also clear that there needs to be a single definition of sepsis within an institution; having one definition applicable to one payer group and a second for another is counter-intuitive to clinical thinking. Whichever definition is adopted by your medical staff, consistency matters.

(FYI, the Zephyrus line is from the prologue to the Canterbury Tales. Some days I have to use that English Literature course I took. And if you want another sepsis article that pays tribute to fine literature…namely Gabriel Garcia Marquez…check out “SIRS in the Time of Sepsis-3,” in Chest.)

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at or follow his personal blog at Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

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ACDIS Guidance, Clinical & Coding