Q&A: Clinical criteria guidelines for sepsis

Q: What criteria guidelines are you utilizing for sepsis (i.e., Sepsis-2, sequential organ failure assessment [SOFA], etc.)? Do you adjust criteria based on payer? We’re currently using Sepsis-2 for all payers.

Response #1: Several years back, before I was the head of the department, our administration came to me and the director, informing us that we would need to use payer-specific guidelines per our insurance contract language. We started using Sepsis-2 for Medicare and Medicaid and Sepsis-3 for managed care and commercial payers. The adjustment took a great deal of physician education. We had an EPIC smart phrase built-in to include a statement of “sepsis as evidenced by [insert infection] by the following criteria,” and we listed all the Sepsis-2 and Sepsis-3 criteria that they could choose from. Though they often still do not get it exactly right, and though the education process continues, we have seen our sepsis denials decrease.

We also include a CDI-calculated SOFA score when we query as well. Our CDI department used to be siloed by each individual hospital, but the CDI department was merged into one system unit in October. Since then, I have implemented this same process at the other two sister hospitals and trained the other staff from those two hospitals. The entire department is now reviewing with Sepsis-2/3 criteria per payer and it has worked well.

Response #2: I feel your pain with sepsis and other diagnoses too. With sepsis, we will clinically validate if the case has only two systemic inflammatory response syndrome (SIRS) criteria and a source of infection (especially if the SIRS criteria is a respiratory rate and tachycardia). We will ask for sepsis using Sepsis-3 criteria because we want the end organ dysregulation. We do not use various criteria based upon insurance companies.

Response #3: We created criteria that combines Sepsis-2 and Sepsis-3. We collaborated with our physician advisors from the medicine and MICU on the criteria. We have a standard operating procedure (SOP) but it’s only for CDI, inpatient facility coding, inpatient nurse auditors, and our educators. We don’t have an enterprisewide accepted criteria at our facility, but most of our providers agree with these indicators. We have a PowerPoint slide with the indicators and then a formalized SOP document.

We do not adjust by payer as we felt this could potentially be a compliance risk as well as for consistency with queries for our providers. I know some pre-bill vendors that do this, but we do not (at least at this time). Our vendors are required to follow any of our clinical SOPs for our facility.

Response #4: We do get denials from payers using Sepsis-3 and will continue to appeal based on the criteria we use aligned with CMS and our provider’s practice. Oftentimes, when we are creating the appeal, we find that Sepsis-3 was indeed met so we also include that piece. We win some and lose some but appeal them all!

Response #5: We switched our system sepsis guidelines to Sepsis-3 about 18 months ago. Despite our extensive criteria, sepsis remains our highest denial type. I am sharing an excerpt from our queries to show criteria/guidelines below (our organization does not adjust based on payer).

Based on the clinical data listed below, can this data be further specified with a diagnosis of: 

• Sepsis with acute sepsis-related organ dysfunction 
• Septic shock 
• Localized infection (specify) without sepsis  
• Another condition (Please specify, including etiology) 

Source of suspected or confirmed infection:  

• [***Examples: Pneumonia, UTI, Cellulitis, COVID, etc.] 

Patient clinical appearance:  

• [***Examples: documented as appears ill versus well appearing] 

Identified organ dysfunction WITHOUT an alternative cause:  

• [***Examples: Respiratory failure, coagulopathy, liver failure, shock, encephalopathy, acute oliguria/AKI, critical illness myopathy/neuropathy, type 2 myocardial infarction [MI], transaminitis, hyperbilirubinemia, ileus, etc.] 

Clinical findings [***Note to CDI – show trended labs]: 

• P/F ratio: __________ (calculated from P/F Ratio Calculator) 
• Platelets: __________
• Bilirubin: __________ 
• Creatinine: __________ 
• Glasgow Coma Scale score: __________ 
• BP/MAP: __________ 
• Lactate: __________ 
• Vasopressor [***if any and infusion rate]: __________ 
• Mental status alteration [***if present]: ___________
• Respiratory rate: __________
• Other: __________ 
• SOFA score: __________ (calculated from SOFA Score Calculator) 

Treatment: 

• [***Examples: Antibiotics, fluid resuscitation, vasopressors, oxygen therapy, blood cultures, etc.]

Organization’s approved guidelines 

• Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to a suspected or confirmed infection 
• Septic shock is defined as sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥ 65 mm Hg 

Organ dysfunction 

Systemic 

• Elevated lactate (> 2 mmol/L) before or after fluid resuscitation 

Neurologic 

• Delirium (e.g., CAM positive), encephalopathy or other change in mental status 
• GCS < 15, or GCS decrease of two or more if baseline is less than 15 

Cardiovascular 

• MAP< 70 (or < 65) or SBP < 90 or decrease by > 40 mm Hg from baseline 
• Type 2 MI 

Gastrointestinal 

• Ileus 
• Hyperbilirubinemia (≥ 2.0 or > 2x baseline if baseline is > 1.2) 
• New transaminitis (>2x normal) 

Renal 

• Creatinine increase ≥ 0.5 mg/dl or ≥ 2.0 if baseline unknown 
• Urine output (UOP) < 0.5 mL/kg/hr for two or more hours or UOP < 500 mL in 24 hours 

Pulmonary 

• P:F ratio < 300 or decrease by > 100 from baseline 
• New invasive mechanical ventilation 
• New non-invasive ventilation (CPAP, BiPAP, or high-flow nasal cannula) 
• New supplemental oxygen with objective signs (ex. tachypnea) and symptoms (ex. work of breathing) of respiratory failure due to infection 

Hematologic 

• Platelets < 100 or decrease by 50 or more if baseline is less than or equal to 150 
• INR > 1.5 in the absence of anticoagulation or in the absence of prior abnormal INR due to liver dysfunction 

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and originally appeared in the CDI Leadership Insider, the monthly council-only publication. For the purposes of this article, all Council member answers have been deidentified.