Q&A: Payer sepsis criteria

Q: What sepsis criteria does CMS prefer people use? Do other insurance plans let you know which sepsis criteria they use to review claims?

A: I don’t know that anybody has settled on anything in particular. The insurers, if they don’t choose one set of criteria, can use any of the arguments they want to.

As to which criteria should be used—for any condition, not just sepsis—there simply has to be a preponderance of clinical support to validate that condition.

The issue of which criteria you should be using is really a moot point because, when it comes to whoever is on the other side of the claims (the payer), they can use whatever criteria that they want if they need to. The issue is that you have to have evidence to support to clinical validity of the condition on your side. That’s really what it comes down to.

If they hit you with quick sequential organ failure assessment (qSOFA) criteria, you will be able to defend your case by using other known criteria that are self-evident and supportive of sepsis for that patient. So, they may say the case doesn’t fulfill qSOFA, but you can then come back and say that the patient has a lactic acid of two or four and that the only thing that can explain that for the particular patient is sepsis.

Having that evidence is really the thing that can help overturn the payer’s dependence on sepsis 1, sepsis 2, or sepsis 3 criteria, because they can really use any that they choose that will defend their denial.

Editor’s note: Shelly McBrayer, BSN, RN, CCS, CCDS, CDI coordinator at Chesapeake (Virginia) Regional Healthcare and Cesar M. Limjoco, MD, CDI physician advisor consultant, answered this question during the webinar “Sepsis: Resolving Documentation and Coding Conflicts through CDI,” originally broadcast on July 19. The session will be rebroadcast on October 18, 1-3 p.m. eastern. Click here to learn more.