Journal excerpt: Sepsis criteria challenges

CDI Strategies - Volume 14, Issue 51

Because of the industry’s confusion over sepsis criteria sets, organizations find it difficult to decide which guidelines to follow for their sepsis documentation.

“Many third-party payers have adopted Sepsis-3 criteria, which is not in line with what CMS is doing,” says Krysten Brooks, RN, BSN, MBA, senior healthcare performance advisor with 3M Health Information Systems, headquartered in Salt Lake City, Utah. “It’s important to remember that the first level of sepsis as defined in the SIRS criteria is not reflected in Sepsis-3. In SIRS, we evaluate for sepsis, severe sepsis, and septic shock, while in Sepsis-3 we’re looking for only the two severe types of sepsis.”

CDI professionals need to understand the difference between CMS criteria and Sepsis-3, she says.

CMS introduced its core measures back in 2016, and while voluntary, its sepsis-related elements can affect quality reporting and value-based purchasing, Brooks says. “CMS wants organizations to recognize and treat sepsis early while documenting it appropriately.”

If a facility follows Sepsis-3 criteria but not CMS SIRS criteria, they may be under-reporting regular sepsis which may affect their quality metrics and their success under value-based purchasing. A hospital’s severity scores and likely its observed-versus-expected mortality scores may suffer in comparison with peer hospitals, suggesting the hospital is providing poor care to not-very-sick patients, Brooks says.

In contrast, organizations often forget that with Sepsis-3, they’re not being graded on regular sepsis, but are being scored on the bundle of severe sepsis and septic shock.

“While you still want to be reporting sepsis, remember that you’re being scored from a quality perspective on severe sepsis and septic shock,” says Brooks. “That takes the sting out of which criteria to follow.”

Editor’s note: Read this full CDI Journal article here.

Found in Categories: 
Denials & Appeals, Clinical & Coding

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