The patient story is paramount to validating a diagnosis of sepsis.

MS-DRGs 872 and 871, Septicemia or Severe Sepsis with MCC and without MCC, respectively, are problematic, from a compliance and reimbursement perspective. Most commercial payers, including Medicare Managed Care organizations, have put these two MS-DRGs under heightened scrutiny due to increased coding and billing from providers, driving costs of inpatient hospital care continually higher. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has consistently signaled concern with potential “upcoding,” with the most recent example expressed in a recent report issued in February, titled “Trend Toward More Expensive Inpatient Hospital Stays in Medicare Emerged … and Warrants Further Scrutiny” (OIG Report). Several key takeaways from the report are as follows:

  • Hospitals billed Medicare for 8.7 million inpatient hospital stays in the 2019 fiscal year (FY). About 40 percent of them – 3.5 million stays – were billed at the highest severity level. These are generally stays for which the hospital bills at least one major complication.
  • Medicare spent $109.8 billion for inpatient hospital stays in FY 2019, and nearly half of that – $54.6 billion – was for stays billed at the highest severity level. Medicare paid an average of $15,500 per stay billed at the highest severity level.
  • The most frequently billed MS-DRG in FY 2019 was septicemia or severe sepsis with a major complication (MS-DRG 871). Hospitals billed for 581,000 of these stays, for which Medicare paid $7.4 billion.

UnitedHealthcare (UHC) just announced a new policy, effective July 1, 2021 addressing their apparent concern with sepsis coding and billing. In it, UHC notes that it reserves the right to review sepsis DRGs, prepayment as well as post-payment. As things currently stand, UHC’s policy for sepsis billing permits just post-payment billings (UHC Sepsis Policy).

Providers must take note of this new policy and ensure that they are producing clinical documentation that incorporates the clinical information, facts, and context, as the specific indicators support the diagnosis of sepsis.

Sepsis Poses Potential Compliance and Financial Risk
In my personal experience, sepsis DRGs billed by hospitals are consistently increasing in number over time, creating cause for potential concern from a compliance and financial perspective. Most hospitals are receiving increasing numbers of clinical validation denials associated with sepsis billings, under the premise that provider documentation does not support the diagnosis of sepsis. In a good number of instances, the clinical indicators may support the diagnosis of sepsis using whatever sepsis criteria the hospital utilizes, while in other instances, the clinical indicators as recorded in the documentation may not support the diagnosis. In still other instances, provider documentation may clearly support sepsis in all facets, yet the payer still challenges the diagnosis just because they can, in the name of saving money outlays and containing their medical loss ratio.

So, what is my concern for potential compliance and financial risks associated with sepsis coding and billing? First and foremost is my validated concern with over-querying for the diagnosis of sepsis by clinical documentation improvement (CDI) specialists, perpetuated by current key performance indicators that promote generation of queries. Number of records reviewed, number of queries issued, CC/MCC capture rate, and physician response to queries are just several of the measures of performance used by the CDI professional. Indirectly or directly, queries have the potential to increase compliance and financial risk attributable to possibly insufficient and/or incomplete documentation that adequately reflects a clear patient story.

This patient story is paramount to validating a diagnosis of sepsis. The clinical indicators utilized in a query or included in the provider’s documentation are just one subset of what needs to be done. The clinical picture as depicted by the provider’s documentation in the history and physical are paramount to alleviating any unnecessary compliance and financial risk to the hospital, as well as the physician. Consider the following case, in which the payer wanted to downgrade a sepsis with acute metabolic encephalopathy diagnosis to a simple UTI:

  • MS-DRG 871- Septicemia with MCC
    • PDX: Sepsis
    • Secondary: Acute metabolic encephalopathy
    • Constitutional Physical Exam: Alert and oriented, in no current distress, resting comfortably on the edge of the bed, just finishing eating a cheeseburger and fries while talking to the nurse.

Final Thoughts
While this may be the extreme, I consistently observe inconsistencies in documentation that payers latch on to in order to refute the diagnosis of sepsis. All CDI professionals must be cognizant of the need for complete and accurate documentation that clearly captures a clinical picture of a truly “septic” patient. Do not allow the payer the opportunity to capitalize upon incomplete and/or insufficient provider documentation that affords the opportunity to deny sepsis (or, for that matter, any diagnosis). Take the time to review the entire record holistically, beginning with the history and physical, recognizing documentation insufficiencies within the documentation, and most importantly, addressing them with the provider. It is time to “educate versus “query-ate” as the most constructive and effective approach to actually achieving real documentation integrity that is sustainable over time. There is simply much more to CDI than capturing CCs/MCCs with the goal of increasing the case mix index.

Without sufficient provider documentation or a strong commitment to clinical documentation excellence, hospitals will face increasing volumes of clinical validation denials and assertions of upcoding, playing into the hands of all payers- not to mention Recovery Audit Contractors (RACs), the OIG, Medicare Administrative Contractors (MACs), and other Centers for Medicare & Medicaid Services (CMS) contractors.

The profession must recognize that from a payer perspective, “just because a physician says a patient has a diagnosis does not necessarily mean it is so.” Take the extra time to review the chart; embrace the concept of holistic chart review.

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