Guest Post: Sepsis headaches

By Howard Rodenberg, MD, MPH, CCDS

Before my time in CDI, in the cold, deep darkness of the ED night, sepsis was an annoyance. Everywhere there was a sepsis flag popping up in the EHR, few of which actually meant anything.

Tachycardia? Maybe it’s sepsis, or maybe it’s meth.

Elevated WBC? Maybe it’s sepsis, or maybe it’s the slug of steroids I just gave to the asthmatic or the demargination of leukocytes that follows a seizure.

Tachypnea? Maybe it’s sepsis, or maybe it’s that you’re anxious I won’t refill your opiates.

Sometimes the flag would popup based on triage data before you even stepped into the room, and you had to answer the question of whether you were treating sepsis or document why not even before you had laid eyes on the patient. Woe to you if you admitted a patient who met systemic inflammatory response syndrome (SIRS) plus infection criteria on paper but you didn’t think was actually septic. And there was no discrimination between sepsis and severe sepsis; in either case, you would get called out for not giving enough fluids (I thought drowning in congestive heart failure was bad, but what do I know?) or not drawing lactic acid at exactly the right times.

The more things change, the more they stay the same. Sepsis is still an annoyance, though this time it’s mired in the alphabet soup of Sepsis-2 and Sepsis-3 and CMS SEP-1 and Surviving Sepsis and there’s probably even a mascot called Sammy the Sepsis Snail out there somewhere. CMS is still on the side of Sepsis-2, while private payers and auditors are all about Sepsis-3. I bring this up not to tell you how I personally feel about Sepsis-2 versus Sepsis-3. But I do believe that a hospital has to make an institutional decision about what sepsis is within its walls.

What definition should you adopt? Sepsis-2 or Sepsis-3? Until there’s a clear clinical consensus one way or the other (and given the politics of medicine, I don’t think that’s coming anytime soon), might I suggest there might be an economic model that can guide your thinking?

Let’s assume that the current positions of CMS and private payers are entrenched, like a WWI battlefield. With opinion divided, you’ll want to join the side that has the most to offer and provides you the most to gain. And you’ll need data to make that decision.

The two key pieces of information to know are your payer mix and the number of patients currently diagnosed with sepsis (via a “sepsis DRG” 870-872) by Sepsis-2 and Sepsis-3 criteria, respectively. If you know these factors, I think you can construct an economic argument to point you one way or the other.

Here’s an example of how this might work. Let’s say Hospital A’s payer mix is 40% Medicare, 15% Medicaid, 35% private payer, and 10% self-pay. Let’s assume that Medicare and Medicaid use Sepsis-2, while the private payers are all going to switch to Sepsis-3. (We can drop self-pay from the analysis on the front end; although many may qualify for assistance, it’s not a predictable number). Assuming an equitable distribution of sepsis cases, we have 55% of cases eligible for payment under Sepsis-2 and 35% under Sepsis-3. Sepsis-2 is the broader and more inclusive definition, and more likely to identify cases for reimbursement. So if you have to choose, you pick Sepsis-2.

But the real world isn’t that clear, and this is where the second data point enters the picture. The prior analysis assumes that all sepsis patients are created equally, and that the definitions for Sepsis-2 and Sepsis-3 are mutually exclusive; that is to say, a patient cannot meet the criteria for both definitions.

But what if that’s not true? What if, after a painful session of chart reviews, you find that fully half of your Medicare and Medicaid patients diagnosed with sepsis actually meet Sepsis-3 criteria? In that case, it’s the 35% private payers plus 50% of the government payers (27.5% of the total), giving you potential revenue from 62.75% of patients. Assuming all your private payer cases also meet Sepsis-3 criteria, becoming a Sepsis-3 institution is in your best interest.

On the other hand, if you find that a minority of patients in both groups meet Sepsis-3 criteria, it makes more sense to stay with Sepsis-2, as there are private payers you’ll lose anyway even with a switch to the new criteria but you’ll keep all the government dollars. Realistically, I think this is much more the likely scenario, and I think the literature would support the idea that a minority of all-payer patients diagnosed with sepsis per Sepsis-2 actually meet Sepsis-3 criteria, whereas virtually all Sepsis-3 patients also meet Sepsis-2 criteria.)

Does this idea, this model of thinking, fully resolve your dilemma? No, it does not, and it’s not meant to do so. Institutional preferences count, and changes in medical thought and practice may drive a more definitive result. But hopefully it gives you another approach to consider as you move towards answering the question of defining sepsis in your own shop.

I got so excited think about this I got tachycardic. A pop-up just showed up on my word processor. I might be septic. Does that mean I can go home?

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com. 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.