Master the upcoming ICD-10 code and IPPS changes! Prepare your team for the upcoming changes taking effect on October 1. Discover the benefits of IPPSPalooza and how it can drive your success. Click here >
The biggest holdout to Sepsis-3 is still CMS.
UnitedHealthcare has announced that it will be adopting the Third International Consensus Definition for sepsis and septic shock for all of its lines of business, effective Jan. 1, 2019.
This definition is better known as “Sepsis-3.” The announcement is significant because it informs providers what standard UnitedHealthcare and its contractors will use during sepsis-related clinical validation audits. Presumably, it should also inform what UnitedHealthcare will report to the Centers for Medicare & Medicaid Services (CMS) when reporting sepsis diagnoses for capitation payment calculations.
That UnitedHealthcare is doing this should not be a surprise to the medical community. After all, many payers adopted Sepsis-3 long ago. Why? It’s because this definition identifies fewer cases of sepsis than Sepsis-1 or Sepsis-2. It offers a higher bar than the prior versions, which were based on SIRS (Systemic Inflammatory Response Syndrome) criteria. However, regardless of the impact of sepsis on DRG payments, we must look at the direction of the broader medical community.
Since the publication of the Sepsis-3 definition in February 2016, recognition of it has gradually become more widespread in the medical community. Studies have shown that the Sequential Organ Failure Assessment (SOFA) score, the basis of the clinical criteria for Sepsis-3, consistently outperforms SIRS criteria in the identification of patients at high risk of dying. The Surviving Sepsis Campaign incorporated Sepsis-3 into its guidelines in 2017. The medical reference UpToDate, while acknowledging that Sepsis-3 is not universally accepted, writes that SIRS criteria have fallen out of favor, since its parameters are quite non-specific.
The biggest holdout to Sepsis-3 is still CMS, which rolled out its Sepsis-1 core measure, based on Sepsis-1 and Sepsis-2 criteria, shortly before the publication of Sepsis-3. However, a meta-analysis of the CMS measure published in the Annals of Internal Medicine in April, as well as a more recent study published in Critical Care Medicine this month, failed to show a correlation between Sepsis-1 core measure adherence and improved sepsis outcomes.
The biggest criticism of Sepsis-3 has been that it might delay treatment for sepsis, because SOFA requires more time to develop and score than SIRS. Critics have asked, should the studies that showed aggressive and protocolized treatment of sepsis diagnosed by SIRS criteria be thrown out, simply because a panel decided to change the research definition? Actually, I’m with the Sepsis-3 authors here, because if you look at those studies, none used SIRS as the sole inclusion criterion. Patients not only had SIRS, but also had to have evidence of organ dysfunction, hypotension, or septic shock in order to be included in the study.
The Sepsis-3 authors essentially took the stance that SIRS was the less important and less specific entry criterion. In other words, how many really sick people did these studies exclude from potentially beneficial treatment because they had to meet SIRS criteria as well? Sepsis-3 is defined in a manner meant to identify the really sick folks, emphasizing that organ dysfunction and shock recognition is not enhanced by additionally applying SIRS criteria.
Earlier this year, the Surviving Sepsis Campaign attempted to address early treatment of sepsis by proposing an “Hour One Bundle” for sepsis treatment, with antibiotics and IV fluids administered within one hour of ED triage presentation. However, the Infectious Disease Society of America voiced strong opposition to this, fearing that many non-septic patients would be treated unnecessarily or even harmed by such an aggressive timeframe. They cited data that already as many as 40 percent of “sepsis” admissions to the ICU do not actually have infections, and thus by definition cannot be septic. In response, the Surviving Sepsis Campaign has been put in the awkward situation of putting forth the Hour One Bundle but then asking hospitals not to implement it until more expert discussion can occur.
It is clear to me that Sepsis-3 is here to stay for the foreseeable future, and I commend UnitedHealthcare for recognizing that and adopting an emerging standard in sepsis diagnosis. It is also becoming clearer to me that how we define sepsis may not be critical to the process of recognizing bad infections and initiating early, aggressive treatment.
What’s wrong with worrying about whether to label it “sepsis” later?
EDITOR’S NOTE: The following op-ed is exclusively comprised of the opinions of the individual author, which are not necessarily shared by RACmonitor or Monitor Mondays.
Just as the role of physician advisors has come to the forefront of the healthcare world over the last decade and a half, so too
Please log in to your account to comment on this article.
The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.
A massive task lies ahead! Now’s the time to start preparing your case management and utilization review teams for successful implementation of changes contained in the 2024 IPPS, OPPS and MPFS rules.
Gain clarity on billing, patient notifications, and discharge appeal rights in social admissions. Join our webcast for essential insights and strategies to navigate this complex landscape, ensuring financial stability and optimal patient care.
Dr. Ronald Hirsch provides tried-and-true strategies and insight into outpatient in hospital bed stays including determining the applicable definition, who uses it, and when and how to bill for this circumstance, solidified with concrete case examples and expert insight.
Explore comprehensive guidelines and best practices for secondary diagnosis coding in our illuminating webcast. Delve into the intricacies of accurately assigning secondary diagnosis codes to ensure precise medical documentation. Learn how to navigate complex scenarios and adhere to coding regulations while enhancing coding proficiency. Our expert-led webcast covers essential insights, including documentation requirements, sequencing strategies, and industry updates. Elevate your coding skills and stay current with the latest coding advancements so you can determine the correct DRG assignment to optimize reimbursement, support medical decision-making, and maintain compliance.
Enhance your inpatient coding precision and revenue with Principal Diagnosis Coding: Mastering Selection and Sequencing. Join our expert-led webcast to conquer the challenges of principal diagnosis selection and sequencing. We’ll decode the intricacies of ICD-10-CM guidelines, equipping you with a clear grasp of the rules and the official UHDDS principal diagnosis definition. Uncover the crucial role of coding conventions, master the sequencing of related conditions, and confidently tackle cases with equally valid principal diagnoses.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY24 Inpatient Prospective Payment System (IPPS) Final Rule, including new ICD-10-CM/PCS codes, plus insights, analysis and answers to questions from the country’s most respected subject matter experts.
This third session in our 2024 IPPS Summit will feature a review of FY24 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from two acclaimed subject matter experts
Copyright © 2023 ICD10monitor. Powered by MedLearn Media.
