Revisiting Sepsis  

Did you know it is Sepsis Awareness Month? To be honest, I didn’t, until a recent Agency for Healthcare Research and Quality (AHRQ) newsletter informed me of such.

As hard as we try to educate providers about how to best document so patient acuity can be accurately reflected within the ICD-10-CM/PCS code set, sometimes it feels like we haven’t really made much progress. Maybe a better strategy is for clinical documentation integrity (CDI) professionals to embrace this and other such designations as an opportunity to create an educational campaign.

AHRQ has a lot of free resources on the topic of sepsis, including the 95-page Report to Congress: An Assessment of Sepsis in the U.S. and its Burden on Hospital Care (September 2024). Not surprisingly, this report found a nearly 40-percent increase in inpatient stays attributed to sepsis between 2016 and 2021. I’m sure this statistic is not that surprising, since sepsis is one of the top five (if not the top) MS-DRGs for most hospitals.

It’s hard to know if this increase in sepsis is due to better detection and reporting of sepsis, or overreporting of sepsis based on an outdated clinical definition. I’m purposely using the term “outdated” based on a recent U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) scope of work.

The OIG is currently reviewing Medicare inpatient billing for sepsis, with an expected report release date of 2026. As many of us already know, there are two primary definitions currently used when diagnosing sepsis. What the OIG refers to as an “older, broader” definition is what most of us refer to as SIRS (Systemic Inflammatory Response System) plus infection, also known as sepsis 2; there is also the SOFA (Sequential Organ Failure Assessment), also known as sepsis with organ failure, or sepsis 3.

The OIG states that “there is concern that hospitals may be taking advantage of this broader definition, as they have an financial incentive to do so.”

The Centers for Medicare & Medicaid Services (CMS) once stated that there is nothing wrong with hospitals taking full advantage of compliant documentation and coding opportunities. Currently, without a standardized national sepsis definition, many payers will remove sepsis from a claim if it cannot be validated using sepsis 3 criteria. Even the OIG stated that CMS and the Centers for Disease Control and Prevention (CDC) use the older, broader definition, so why should hospitals be penalized for using it?

As this battle over how to define sepsis continues to rage, I wonder: does it really matter? Hospitals are pressured to quickly identify and intervene, because sepsis is a global health priority due to its high morbidity and mortality, but those same hospitals are penalized when the patient positively responds to quick intervention. Payers issue denials because the patient recovered too quickly, but did the provider know the patient would have such a positive outcome? Of course not.

The provider implemented evidence-based care, because it was what is best for the patient. We’ll never know if the outcome would have been worse without this early intervention. Providers are caught in the crossfire. AHRQ reports that one in three hospital mortalities are from sepsis.

The CDC published the Hospital Sepsis Program Core Elements: 2023, wherein hospitals are encouraged to create sepsis programs that “facilitate recognition of sepsis, evidence-based management of sepsis, and longer-term recovery from sepsis (p. 8).” To this end, hospitals should have “a standardized process to screen at-risk patients for sepsis upon presentation to the hospital and throughout their hospitalization,” because early treatment saves lives (p. 8).

The problem, according to the CDC, is that although the 2021 Surviving Sepsis Campaign recommends a strong screening process, it does not recommend a specific tool or approach.

The CDC offers a website Resources | Sepsis | CDC that has several sepsis references, including screening tools, clinical pathways, regulatory references, and educational resources. As part of the “Get Ahead of Sepsis” Campaign, the CDC offers a couple of different “Protect Your Patient from Sepsis” resources.

These resources for healthcare providers include a section with the signs and symptoms of sepsis, as follows:

• High heart rate or weak pulse;
• Confusion or disorientation;
• Extreme pain or discomfort;
• Fever, shivering, or feeling very cold;
• Shortness of breath; and
• Clammy or sweaty skin.

I don’t know about you, but I don’t find this guidance to be very sophisticated. Maybe that is the point? AHRQ also acknowledges that diagnosing sepsis in adults is challenging, “as presentation is often subtle, the time of onset usually unknown, and symptoms may be attributed to non-infectious conditions (p. 12).”

Yes, as CDC and OIG have identified, there are variations in coding practices when it comes to sepsis, but research has also demonstrated that “sepsis quality improvement initiatives that raise provider awareness can lead to stage migration by including more patients with milder disease, thus lower perceived sepsis mortality (p. 14).” The AHRQ Facilitator Guide for the Best Practices in the Diagnosis and Treatment of Sepsis acknowledges that sepsis presents differently within any given population, and “there is no gold standard test for sepsis, developing diagnostic criteria for sepsis has been challenging and is evolving over time.”

Maybe we need payers to stop using positive outcomes as a reason to deny that a patient had sepsis. As I’ve mentioned in other past articles, it seems like the insurance industry is losing sight of patients.

Don’t we want our insurance companies, including Medicare and Medicaid, to do what is best for each patient? Don’t we want early intervention to reduce morbidity and mortality? The fact of the matter is that most suspected cases of sepsis are treated with the same resources as confirmed cases of sepsis. The AHRQ Report to Congress states that “sepsis is one of the most expensive conditions treated in the United States.”

What varies is the duration and aggressiveness of treatment, based upon the patient’s response.

The AHRQ Best Practices Facilitator Guide states that “sepsis is often challenging because a patient is evaluated at one point in time. At the time of assessment, the clinician may not have complete information on the trajectory of illness prior to this point and obviously does not have knowledge of the trajectory of illness in the future.” Three patients with the same presentation could have substantially different trajectories, with one or more terminating in the outcome of death. It is better to start antibiotics and later discontinue them than to wait? Again, what is best for the patient? Intervene early and risk not being reimbursed for the expended resources, or wait until the patient meets all the clinical criteria required by payers before expending resources? Is patient care a clinical decision, as practiced by hospitals, or merely a financial decision, as practiced by payers?