Q&A: Sepsis appeals

Q: Are institutions appealing sepsis denials if the patient meets sepsis-2/super systemic inflammatory response syndrome (SIRS) criteria, but not sequential organ failure assessment (SOFA) criteria? We have one hospital in our system that uses only sepsis-2 as their criteria, and many of them have been denied due to the lack of “remote” organ failure, even though the patient does have organ failure; Sepsis-3 is always referenced in the denial letter. Is there any advice for how to handle these situations?

A: First, it may be helpful to create a standard template to be used for all appeals regarding the payer’s “remote organ failure” argument. Keep sending the same appeal until either it is accepted, or they ask you to stop sending it.

That being said, in general when a patient has a diagnosis like sepsis with pneumonia and acute respiratory failure, or sepsis with pyelonephritis and acute kidney infection, it’s a good idea to ask the provider if they feel this organ dysfunction is beyond what would be expected in the normal disease process.

While providers may not be receptive to discussing the nuances of the sepsis-2 versus sepsis-3 denials landscape, educating them on documenting sepsis with or without organ failure may be helpful. This documentation in the future may help with avoiding the “remote organ failure” argument from payers.

Editor’s note: This question and answer were adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.