Although clinical standards are constantly evolving as medical evidence and treatments emerge, the diagnosis of sepsis has been an area of active debate over the past decade for payors, providers, and researchers. One reason for this is its high mortality rate, combined with significant diagnostic overlap with less dire clinical conditions in its early stages, when intervention is most effective. The other is that it is one of the most common and highest-cost medical diagnoses in DRG coding in the acute and post-acute settings.
Enter the recent Society of Critical Care Medicine consensus definitions for sepsis and septic shock (Sepsis-3), aimed at improving the predictive value of diagnostic findings in management and identification of sepsis, as well as clarifying intervention options. Not unexpectedly, this has had the unintended consequence of providing payors such as Anthem and UnitedHealthcare with credible ammunition to redefine their reimbursement criteria, resulting in denials and lower reimbursement for the same diagnosis, essentially shifting the bar.
The Coding Challenge for Sepsis
The challenge is that there are no real national standards for coding, except for CMS’s standard, which applies only for Medicare and Medicaid. The commercial payors can essentially do what they like in determining coding criteria, though they generally need to point to some “standard” that clinically supports their approach, mainly as a hedge against legal challenges.
The real issue is that the new Sepsis-3 criteria are actually more clinically appropriate when defining what true sepsis looks like. As clinicians, we’ve long used the “sepsis” label when in doubt, because criteria were relatively loose, making “sepsis” one of the most common coding diagnoses on the acute side. This is partly due to a lack of more appropriate codes, such as “symptomatic bacteremia” or “UTI with bacteremia.” Most of the debate in the clinical literature is not about the retrospective diagnostic validity of the criteria for coding but about their predictive value in management and identification for individual cases, which is a different, and entirely clinical, matter.
Commercial Payors and Sepsis-3 Criteria
In truth, commercial payors are beginning to employ the new criteria only because they’re much more stringent and will reduce sepsis incidence rates (and reimbursements). It’s just the payors’ luck that the criteria also happen to be more diagnostically appropriate. When we consider the rising incidence of many other diagnoses due to how criteria generally evolve, it’s something of an anomaly that sepsis becomes clinically less common under these criteria.
Navigating the Reimbursement Landscape for Sepsis
It’s likely that the tide will continue to shift quickly among commercial payors in markets across the country in favor of increased denials and lower reimbursements based on these new criteria. Although CMS is still following the Sepsis-2 (SIRS) standard for diagnosis and coding, we expect that CMS will adopt the Sepsis-3 criteria within the next two to three years.
It will also be important to understand the denial impact that may result from a timing difference between payors and coders moving to the new guidelines. At a system level, it will be critical to have leadership support a defined process to monitor, provide education on, and resolve any denial issues that may arise.
Implementation of the necessary diagnostic criteria at hospitals will be a significant change to standard processes, order sets, and documentation templates and will ultimately still result in some loss of revenue based on the more strictly accurate criteria. That said, the cost of not implementing this change from a compliance and reimbursement perspective will be much more dramatic, leaving additional revenue on the table as time progresses through down-coding and denials. Though managing the change will be painful in the short term, there will also likely be immediate gain in current coding regimens by improving documentation to move existing lower-reimbursement cases to higher-reimbursed DRGs.