Q&A: Sepsis criteria conundrum

Q: Which sepsis criteria should we use? It seems like we get denials quoting every criteria set and are at a loss for how to prevent them or respond.

A: This is a challenging dilemma for every hospital. First, the Medicare inpatient quality reporting (IQR) program for its sepsis quality measure (called SEP-1) requires hospital quality departments use the National Quality Foundation's (NQF) severe management sepsis bundle (NQF #0500) for reporting, which is derived from the sepsis-2 definition of sepsis as systemic inflammatory response syndrome (SIRS) due to infection using two or more of the following:

• white blood cell count
• temperature
• respiration
• pulse

And only certain particular organ dysfunction criteria to identify severe sepsis.

Many payers, however, have changed from sepsis-2/SIRS criteria to sepsis-3 for clinical validation of a sepsis diagnosis. If the diagnosis of sepsis on a claim is substantiated in the record only by sepsis-2/SIRS criteria, the diagnosis may be removed from the claim based on not meeting sepsis-3 criteria. A possible solution for this perplexing dilemma is for the medical staff to use both sepsis-3 and sepsis-2 criteria to screen patients for severe sepsis and to initiate the NQF severe sepsis bundle. If the record only substantiates severe sepsis based on SIRS criteria, so be it and let the “chips fall where they may” with the payers. 

One more word of advice when a claim for sepsis is denied because sepsis-2/SIRS criteria were the basis for the diagnosis. In those instances, review the record carefully for sepsis-3 criteria that may have been otherwise overlooked. It’s a good appeal opportunity.

This dilemma is addressed briefly by a paragraph on p. 203 of the 2019 CDI Pocket Guide section on sepsis-3 as well. I hope this more detailed analysis helps all those affected by this problem.

Editor’s note: Richard Pinson, MD, FACP, CCS, answered this question. Pinson is the principal and medical director at Pinson and Tang LLC and the best-selling coauthor of the CDI Pocket Guide, the Outpatient CDI Pocket Guide: Focusing on HCCs, and the Pocket Guide for Coding Professionals. We are also pleased to announce that the 2020 version of the CDI Pocket Guide is now available for pre-order. Dr. Pinson can be contacted at info@pinsonandtang.com. Opinions expressed are that of the author and do not necessarily reflect those of ACDIS, its Advisory Board, HCPro, or any of its subsidiaries.