Sepsis and HCCs – Too Many or Too Few?

Like many of you, I am deathly allergic to clinical documentation integrity (CDI), but do not worry; I premedicated with prednisone and an antihistamine prior to writing this article.

I know it is critically important that doctors use the right terminology for diseases so that all those agencies – both governmental, like the Centers for Medicare & Medicaid Services (CMS), and profit-driven, like US News – can measure something to set payment rates and publicly report what they consider to be measures of the quality of care provided by hospitals. And of course, we all have heard how many payers develop their own definitions of diseases in an attempt to deny adequate payment to providers.

Who knew that a patient with Medicare could be considered to have malnutrition, but that same patient would be considered properly nourished if they switch to a Medicare Advantage (MA) plan? I don’t think we acknowledge how well MA plans are able to cure so many diseases so quickly.

But the real reason I bring this up is to address a commonly debated diagnosis – sepsis. And to get right to the point, we finally have an official government agency telling us how they define sepsis. We did get a hint of this coming when, in March 2024, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) announced that they were going to audit sepsis, as they felt that many hospitals were using the older definition of sepsis because there was a financial incentive to doing so.

But now, the Government Accountability Office (GAO), which audits every facet of government, including spending, in its audit of the quality of the medical care provided at U.S. Department of Defense facilities, defines sepsis as “a life-threatening condition caused by the body’s extreme response to an infection that leads to organ dysfunction.”

Now, will this settle the debate? Absolutely not. The GAO is not CMS. The adherents of systemic inflammatory response syndrome (SIRS) will still claim they can code sepsis even though the patient never developed organ dysfunction. But many of us will still see SIRS as warning signs that the patient is at risk of developing sepsis – and that the fast action of the medical team prevented sepsis, so alas, all that can be coded is the infection.

Yep, it’s a flaw in our healthcare system that we don’t get paid as well to prevent a disease as we get to treat the disease, but we must follow the rules.

Moving on, the Annals of Internal Medicine recently published an article looking at coding of diagnoses by MA plans in comparison to Medicare beneficiaries for the year 2021, and it should come as no surprise that MA plan coding of diagnoses classified as Hierarchical Condition Categories (HCCs) greatly exceeded that of traditional Medicare.

Their conclusion was that MA plans were paid an extra $33 billion for that year, with UnitedHealthcare accounting for 42 percent of that extra payment, with a significant proportion of those added diagnoses coming from chart reviews and home-based risk assessments, with vascular disease topping the list of diagnoses.

Now, I do not necessarily fault the MA plans for taking advantage of the rules as they are written. If a diagnosis truly exists that potentially affects the patient’s medical spending, they have every right to capture that diagnosis.

But if they are going to get that extra revenue, they also have to pay some of it out when that patient does need medical care and the provider also follows the rules. I do wonder how many times a diagnosis denied by an MA plan on a DRG validation audit was reported to CMS by that plan as a valid HCC.

And hospitals and health systems should be taking the lead of MA plans. While many concentrate on ensuring that all complications and comorbidities (CCs) and major CCs (MCCs) are captured to optimize the DRG assignment, there is more at stake than the payment for each admission.

The compliant capture of HCCs on the inpatient and outpatient side is not only critical for those who participate in any value-based program, but many of those same diagnoses are used for the myriad of quality programs that result in not only publicly reported quality ratings, but also payment programs for every hospital.