Making the Leap to New Sepsis Criteria

As we reflect on the transformation into spring, with large parts of the country still confronted by temperatures in the mid-30s at night and days when temperatures creep up into the high 70s, we are reminded of the profound disparity that was created between physicians and coders when the Society of Critical Care Medicine (SCCM) updated its sepsis definitions in 2016.

While the industry largely welcomed new, clear, and evidence-based criteria, coders were left constrained by outdated sepsis definitions and coding guidelines. Official coding guidelines still have not been updated to align with the new SCCM sepsis criteria, colloquially referred to as Sepsis-3.

These differences in definition have led to increases in payor denials for sepsis cases, especially in short stays. Nearly every sepsis inpatient claim of less than 72 hours – Medicare, Medicaid, and third-party commercial – is being audited, and in many cases, denied.

With revenue at risk, now is the time for health information management (HIM) and clinical documentation improvement (CDI) leaders to up their game with sepsis. Awareness and process improvement is essential to build consistency across clinical and financial departments, given the new definitions and criteria.

To successfully shift from the sepsis indicators of today to the SCCM criteria of tomorrow, hospitals must recognize the present-day impact on coders while also building bridges through education and monitoring. This article provides practical tactics and logical advice to do just that.

Help Clinical Coders Succeed

Coders face a unique challenge. Until official coding guidance based on the new SCCM criteria is released, they are obliged to assign codes based on physician documentation within the medical record, much of which remains based on old language and definitions. Current coding guidelines state that for a diagnosis of sepsis, there must be a source of infection plus leukocytosis or leukopenia, fever or hypothermia, tachycardia, and/or tachypnea. Additionally, under the new SCCM criteria, such a diagnosis is contingent on the presence of organ dysfunction; however, historically this has been reserved for a diagnosis of severe sepsis.

Physicians still using older criteria may document sepsis when, according to 2016 criteria, the patient is only “at risk” for the disease. Short-stay cases are particularly troublesome for coders. Sepsis is a life-threatening disease and doesn’t justify a quick discharge home from an acute care facility, regardless of what the physician documents.

Use Coding Audits to Ease the Shift

Coding auditors have a bit more flexibility to help facilitate their organizations’ shift to the new sepsis criteria. Auditors are responsible for educating all stakeholders. They should actively push out the new SCCM definitions to all involved personnel, including but not limited to the following:

  • Clinical coders
  • Medical staff (including emergency services)
  • Clinical documentation improvement (CDI) specialists
  • Registration, billing, and revenue cycle staff
  • Denial management teams

Consider Sepsis Pre-Bill Reviews

Payors and their third-party auditors have already begun to use the new Sepsis-3 criteria. In some regions, every case containing a sepsis code is being flagged for additional documentation review, as mentioned above.

To mitigate denial risk, organizations should begin conducting pre-bill reviews of all sepsis cases for which full compliance with the new criteria may not be completely met. Organizations should ensure that the information gleaned from the reviews is communicated to their physicians and education on the impact of this inconsistency is provided.

Recovery Audit Contractor (RAC) audits and third-party payor denials are not going away, but with updated criteria and focused education, healthcare providers can effectively ensure that they are doing everything possible to protect their revenue.

Kim Carr

Kim Carr brings more than 30 years of health information and clinical documentation improvement management experience and expertise to her role as Director of Clinical Documentation, where she provides oversight for auditing and documentation improvement for HRS clients. Prior to joining HRS, Kim worked as a consultant implementing CDI programs in varied environments such as level-one trauma centers, small community hospitals and all levels in between.

Before joining the consultant arena, Kim served as Manager of CDI in an academic level-one trauma center. She was responsible for education and training for physicians and clinical documentation specialists. Over the past 30 years, Kim has held several HIM positions; including HIM Coding Educator, Quality Assurance/Utilization Management Coordinator, DRG Coding Coordinator and Coding Manager. Kim holds a degree in Health Information Management and is a member of AHIMA, THIMA, ACDIS and AAPC.

Cheryl Ericson

Jon has more than 17 years of healthcare experience, both at the bedside and in HIM. Prior to joining HRS, Jon worked in several emergency departments and as a charge nurse in the medical ICU at a level 1 teaching hospital. He has since worked in CDI as both a CDI specialist and analyst, and he currently performs audits for hospitals throughout the country.


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