Sepsis is diagnosed through clinical judgment.
One of the forums I monitor recently saw a question about sepsis and SEP-1, which elicited this article. SEP-1 is the Hospital Inpatient Quality Reporting Program measure titled “Severe Sepsis and Septic Shock: Management Bundle.” The issue that Dr. Todd Brown raised was that using the Centers for Medicare & Medicaid Services (CMS) definition seemed to be resulting in denials from Medicare Advantage plans and insurance companies, and using Sepsis-3 seemed to result in falling out of core measures. He stated that the situation was a catch-22 (if you don’t know what this is, you should really read Joseph Heller’s 1961 book of the same name), and asked how others resolve this issue.
The intent of core measures is to standardize and elevate the treatment of conditions to improve outcomes of Medicare patients. I am not going to address whether SEP-1 is valid and is improving outcomes. I am going to try to help facilities solve their sepsis problem.
Sepsis is a real entity. It is not a made-up condition with whimsical diagnostic criteria. It is, however, diagnosed through clinical judgment. There are no gold-standard clinical diagnostic criteria – not systemic inflammatory response syndrome (SIRS), not Sequential Organ Failure Assessment (SOFA).
The definition is life-threatening organ dysfunction caused by a dysregulated host response to infection. That is the Third International Consensus Definition (Sepsis-3), and that of the Surviving Sepsis Campaign (SSC), which had provided us with Sepsis-2, previously. CMS’s definition, found in Appendix D of the Hospital Inpatient Quality Reporting (IQR) Manual is “presence of pathogenic organisms or their toxins in the blood and tissues or poisoned condition resulting from the presence of pathogens or their toxins as in septicemia.” This is not inconsistent with Sepsis-3.
The first part of CMS’s definition of septic shock is not consistent with current understanding of the pathobiology – “SIRS secondary to a documented infection” – although the rest of the definition reins it back in, noting that “this response is a state of acute circulatory failure characterized by persistent arterial hypotension despite adequate fluid resuscitation or by tissue hypoperfusion unexplained by other causes.” SIRS has fallen out of favor as the criteria for sepsis; it may be an adaptive response to an infection. Patients may demonstrate SIRS in the face of an infection without being septic (e.g., a febrile, tachycardic young adult with a streptococcal pharyngitis). However, abnormal vital signs and an abnormal white blood cell count may often be useful in clueing in the clinician to serious illness.
In order to figure out how to tackle this problem, you must scrutinize the Specifications Manual. The most current complete manual is Version 5.8 (Version 5.8: Discharges 7/1/20 – 12/31/20, https://www.qualitynet.org/inpatient/specifications-manuals#tab2). Version 5.9 simply lays out the exclusion of cases with COVID-19 (principal or secondary diagnosis of U07.1).
There are two mechanisms to trigger the core measure. One, an abstractor picks up the CMS-specified clinical criteria within six hours. The other way is for the provider to document severe sepsis or septic shock. If the patient doesn’t meet the criteria as laid out by CMS, but the provider documents severe sepsis, the patient still falls into SEP-1.
First and foremost, your providers must recognize sepsis: a patient with infection who has organ dysfunction due to a systemic response to the infection. These patients are sick. They look sick. They should be documented as looking sick. If the clinician doesn’t recognize that a patient meets CMS’s criteria – that is, having an infection, two or more abnormal vital signs or WBC count, and organ dysfunction, as specified in SEP-1 – a sepsis review will capture it.
If they recognize it, they need to document that the patient has sepsis. Sepsis is the condition formerly known as severe sepsis, because all sepsis manifests with organ dysfunction now. It is unpalatable to many providers to use antiquated terminology. However, coders are permitted to use the code for severe sepsis if the clinician diagnoses sepsis and acknowledges sepsis-related organ dysfunction (even without using the word “severe.”) CMS specifies documentation of “severe sepsis” and “documentation that is acceptable for severe sepsis” as inclusion criteria for the clinician-identified arm of SEP-1. CMS also includes uncertain diagnoses using qualifiers like “possible, ruled out, suspected, likely, probable, differential diagnosis, suspicious for, and concern for” as meeting criteria.
If sepsis gets ruled out, the provider needs to explicitly document it as soon as possible. If it is within the six-hour window, the sepsis is eliminated as a final discharge code and no longer is in jeopardy of triggering SEP-1 (there needs to be a sepsis ICD-10-CM code for the encounter to be reviewed and abstracted).
Other documentation pointers regarding SEP-1:
- It is supposed to be reflected only in documentation that was part of the medical record available at discharge. Late entries or addenda may be used for abstraction if they were added within 30 days of discharge, but they are not meant to game the system and ensure the passing of a measure.
- If a patient is given palliative care or comfort measures only, it should be documented ASAP. If done within six hours of the sepsis diagnosis, the patient is excluded from SEP-1.
- If hypotension is attributed explicitly to some other cause, such as being normal for the patient due to a chronic condition, medication, or non-infectious etiology, it is not considered sepsis-related hypotension.
- If there is conflicting documentation, the abstraction is based on the latest piece of documentation within the 24-hour period.
- If sepsis is only found in a discharge note, discharge summary, or post-discharge documentation, the case is excluded from SEP-1 and lands solidly in “deny me” territory.
But how do you prevent denials? The provider needs to be telling the story of a septic patient. The general physical exam needs to evoke a sick patient in the mind of the reader. There should be consistency between providers, from specialty to specialty and day to day. The diagnosis should be evolved (from uncertainty to certainty), resolved, removed (from the progress note if it is no longer an active problem), and recapped in the discharge summary, presenting a coherent story of sepsis.
I recommend my macro: sepsis due to (infection) with acute sepsis-related organ dysfunction as evidenced by (organ dysfunction/s). This organizes the provider’s thoughts, supports the diagnosis, and gives the coder permission to code R65.20, Severe sepsis, without making the provider use the outdated term. The clinician must remember to follow the core measures because this documentation will trigger SEP-1, but if they follow these steps, they should also have strong support for the payors to accept sepsis as the diagnosis.
I know it is hard to get your medical staff to change their practice. I have created a provider learning module to explain sepsis to your clinicians. If you go online to https://icd10md.com/icd-10-md-modules/, you can find this module and other useful modules to teach providers excellent documentation. If you use the code “icduniv20,” you can get 20 percent off.
Don’t get dinged when you don’t deserve it, and don’t get denied when you don’t deserve it.
I am preparing my comprehensive COVID webinar for December, and this is a call for PHI-scrubbed cases. If you have had any questions about CDI or coding for COVID-related cases, email us at firstname.lastname@example.org. Help me tailor the webinar to your needs.
Programming Note: Dr. Remer co-hosts Talk Ten Tuesdays with Chuck Buck every Tuesday at 10 a.m. EST.