HIMagine That: Sepsis and clinical denial justification

June 30, 2017 / By Sue Belley, RHIA, Donna Smith, RHIA

Donna:  Hi, Sue – I’ve been hearing that many hospitals are getting denials for records with sepsis coded as the diagnosis.

Sue: Why are they getting denied for that?

Donna: Well, the denials are indicating the documentation does not support the relatively new Sepsis 3 criteria.

Sue: I thought that CMS chose not to follow the Sepsis 3 criteria?

Donna: Have you read the article on the topic?

Sue:  No, I haven’t. Can you send me the link?

Donna:  Sure. I think people should review this article and cite it when they are writing their denial appeal letters.

Sue: Great idea! I’ve suggest to people that the attending physician should be involved in the creation of these clinical denial appeal letters by providing the clinical picture of their patient to support the appeal. Furthermore, the attending physician should sign the letter along with the Chief Medical Officer to impart the significance of the appeal to the agency.

Donna:  Hospitals need to make certain that they discuss and agree upon the clinical criteria they follow for sepsis in their institution. This committee should be composed of physicians (especially Infectious Diseases physicians), CDI specialists, coding professionals and nurses. 

Sue:  You know, some hospitals have rapid response type sepsis teams who respond and deploy when a patient shows any signs of a diagnosis of sepsis.

Donna:  I’ve also heard of sites who changed their coding practices based on denials.

Sue: Oh I know – I recently heard of a customer that no longer codes diagnoses of acute blood loss anemia unless the patient receives a transfusion. Another site will not code the diagnosis unless the hemoglobin falls below 7.

Donna: Don’t the coding guidelines state that these diagnoses should be coded as long as they meet the UHDDS guidelines for coding and reporting of secondary diagnoses?

Sue: Absolutely!  In addition to not fully representing the patient’s story, the resources used to treat the patient, as well as the financial impact, the non-reporting of valid diagnoses will really skew databases and impact public reporting.

Donna: I think we need to go back to the basics and follow the coding rules and guidelines and reexamine the UHDDS guidelines for reportable diagnoses.   

Sue Belley, RHIA, Donna Smith, RHIA, are with the consulting services business of 3M Health Information Systems.

Mervyn Singer, MD, FRCP1; Clifford S. Deutschman, MD, MS2; Christopher Warren Seymour, MD, MSc3; et al. “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287