Achieving and Protecting

5.30.19

Sepsis Reimbursement

Margaret DeFilippis, JD, RN, CCDS, CDIP, CCS, CPC

AGENDA

The Problem of Sepsis

Achieving Sepsis Reimbursement

Protecting Sepsis Reimbursement

010203

Scenarios04Q & A05

The Problem of Sepsis

The Problem of Sepsis

Prevalence Cost Conflicting Medical Definitions

The Problem of SepsisPREVALENCE Is the most prevalent diagnosis in American Hospitals today. 20.1%-28% of all inpatient admissions are diagnosed with Sepsis.

In 2019, 54% of Hospital Deaths were due in whole or part to Sepsis and in 74% Sepsis was Present on Admission.

Sepsis incidence in the US has increased annually by 8-9% during the past two decades with considerable economic impact and high associated mortality

https://www.cdc.gov/sepsis/datareports/index.htmlhttps://jamanetwork.com/journals/jamanetworkopen/fullarticle/2724768

https://www.jwatch.org/na48619/2019/03/05/large-proportion-hospital-deaths-are-due-sepsis

The Problem of SepsisCOSTS

The estimated cost of Sepsis Management in hospitals ranked highest among all disease states at 30.5 BILLION dollars in 2018.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6250243/ https://www.sepsis.org/sepsis-alliance-news/new-u-s-government-report-reveals-annual-cost-of-hospital-treatment-of-sepsis-has-grown-by-3-4-billion/

The Problem of Sepsis

ExpensesCost of Care: SEP-1 Bundles, Increased LOSCost of Readmission: HRRP

POST-PAYMENT REDUCTIONSDenialsValue-Based Reductions: Quality reductions, Public Reporting, MSPB

REDACTED

The Problem of SepsisConflicting Medical DefinitionsWorld – we’ve got a problem!

First International Sepsis Conference - Uniform Definition Sepsis/Severe Sepsis/Septic Shock

2001 SIRS Criteria Second International Sepsis Conference – Early Identification of People with Sepsis

2002 Surviving Sepsis Campaign (SSC) Global (Medical) Mission to Reduce Mortality – Standard Sepsis Protocols/Bundles

2004 Standardized Treatment Bundles for Sepsis at 6 and 24 Hrs from Admit/Diagnosis2008 Found compliance increased survival 5.4%2012 Standardized Treatment Bundles for Sepsis at 3 and 6 Hrs from Admit/Diagnosis

History of SepsisHow did we get here?

The Problem of Sepsis

Conflicting Medical Definitions2015 SEP-1 Core Measure Sepsis Compliance Certification through Quality Reportingoffered to Hospitals – adopted as USA National Standard of Care and Treatment

2016 Third International Sepsis Conference – SOFA Criteria

2017 CMS Medical IPPS tie payment to participation in Quality reporting which is based on SIRS CRITERIA

2018 CMS Public Availability Compare Sep-1 Data

Where are we now?? 3 valid definitions for Sepsis = SEP-1 + SIRS + SOFA

History of SepsisHow did we get here?

SEP-1 Core Measure Sepsis 2 Sepsis 3The body’s overwhelming Infection or suspected infection. Life threatening organand life-threatening response leading to the onset of SIRS. dysfunction caused byto infection that can lead to Sepsis complicated by organ dysregulated hostseptic shock, tissue damage, dysfunction = Severe Sepsis response to infectionorgan failure, and death.

__________________________________________________________________________________________________________ 2 or more SIRS = Sepsis 2 or more SIRS 2 or more SOFA Criteria+ Lactate = Severe Sepsis+ Hypoperfusion after fluidsOr Lactate> 4 = Septic Shock

__________________________________________________________________________________________________________Quality Reporting Claims Reporting Claims Reporting

____________________________________________________________________________________________Sepsis Alliance CMS – Sep 1 Core 3rd Consensus

(2015) Measure (2018) WHO (2016)______________________________________________________________________________________________

CMS IQR NY Law: Public Health Law, Surviving Sepsis CampaignICD-10 and AHA CC Sections 405.2 and 405.4 of Commercial Payers

Title 10 2019 AMAICD-10 and AHA CC ACEP

(Remember all of these definitions require a Provider’s diagnosis of Sepsis and a Provider’s diagnosis of an associated response beyond the symptoms of local infection.

1 2 3

The Problem of Sepsis

When the following criteria are present in adult patients in the ED or Inpatient Sepsis is likely and every aspect of specific treatment bundles must be given or the Quality Reporting will indicate ”inadequate care” for Sepsis was given:

SEPSIS2 SIRS criteria due to infection (*No bundle requirement)

SEVERE SEPSISSEPSIS plus Lactate > 2 OR Organ Dysfunction:

• SBP < 90 +/OR MAP > 70 +/OR SBP decrease > 40 from known baseline• Creatinine > 2.0 mg/dL +/OR UOP 0.5 ml/kg/hr for > 2 hours• Bilirubin > 2.0 mg/dL• Platelets < 100.000 +/OR INR > 1.5 +/OR PTT> 60 seconds• “Altered Mental Status”(Abstraction may remove a factor due to comorbidity)

SEPTIC SHOCKSEVERE SEPSIS plus “Hypoperfusion despite adequate fluid resuscitation or a lactate > 4 mg/dL”

https://www.acep.org/how-we-serve/sections/quality-improvement--patient-safety/newsletters/march-2016/sepsis-cms-core-measure-sep-1-highlights/

SEPSIS CMS CORE MEASURE (SEP-1) Remember all of these definitions require a Provider’s diagnosis of Sepsis and a Provider’s diagnosis of an associated response beyond the symptoms of local infection.

1

The Problem of Sepsis

For Severe Sepsis, this includes:Within 3 hours of presentation of symptoms or admission:

Measure serum lactateObtain blood cultures prior to antibioticsAdminister antibioticsFluids > 30 ml/kg bolus (if hypotension)

Within 6 hours of presentation:Repeat serum lactate if initial lactate is >2

For Septic Shock this includes:Within 3 hours of presentation of symptoms or admission:

As above for Severe SepsisResuscitation with 30 ml/kg crystalloid fluid

Within 6 hours of presentation:Repeat volume status and tissue perfusion assessment (physical exam or physiologic parameters)Vasopressor administration (if hypotension persists)

(* Patient’s transferred from acute care facility or “comfort care” or die with severe sepsis within 3 hours presentation or Septic Shock within 6 hours presentation or patients receiving IV antibiotics for more than 24 hours prior to presentation of Severe Sepsis or “Administrative Contraindications to Care” - Z91.1X)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5396984/

SEP-1 Treatment Bund In order to be compliant, and not suffer a poor Compare rating you need to meet all the measures 100%.*

1

The Problem of SepsisSEPSIS 2 – SIRS Criteria

Sepsis1. Source of Infection2. 2 or more SIRS factors:

-Temp.>38.3/101 (oral)HR > 90b/m-RR> 20r/m-WBC >12 or <4 c/mcL

or >10% bands

Severe Sepsis1. Sepsis AND2. Related Organ Dysfunction (ANY 1):

CARDIO (SEPTIC SHOCK) : SBP< 90 OR40mm/Hg < baseline OR MAP < 65RESP: Meets criteria for Resp. FailCNS: GCS<14RENAL: creat.>2 or urine< 0.5cc/kg/hr x 2hrCOAG: plat ct. < 100 OR INR> 1.5 OR PTT>60 Liver: bili > 2mg.dL(=32mol/L)Abdominal: Ileus +

LACTATE > 2 mg/dL

2

Remember all of these definitions require a Provider’s diagnosis of Sepsis and a Provider’s diagnosis of an associated response beyond the symptoms of local infection.

The Problem of SepsisSEPSIS 3 – SOFA CRITERIA

Remember all of these definitions require a Provider’s diagnosis of

Sepsis and a Provider’s diagnosis of an associated response beyond the

symptoms of local infection.

ORGAN SYSTEM Score (Source of related infection + 2 or more points = Sepsis)

____ 0 1 2 3 4

Cardiovascular: MAP>70 MAP<70 IV Pressors High Dose IV pressors Very High Dose IV( mg/kg/min) Any Dopamine Dopamine > 5 Pressors, Dopa>15

any Epi, Levo>0_________________________________________________________________________________________________________________

Respiratory:PO2/Fio2 >400 (53.3) <400 (53.3) <300(40) <200(26.7) <100(13.3)mm/Hg: +Resp. support +Resp. support

_________________________________________________________________________________________________________________CNS:GCS: 15 13-15 10-12 6-9 <6

_________________________________________________________________________________________________________________ Renal: Creat mg/dL: <1.2 1.2-1.9 2.0-3.4 3.5-4.9 + >5 +UO: (cc/24h) <500 <200

___________________________________________________________________________________________________________________Coagulation:Plts/10^3/mm^3: >150 <150 <100 <50 <20

____________________________________________________________________________________________________________________Liver:Bilirubin mg/dL: <1.2 1.2-1.9 2.0-5.9 6.0-11.9 >12.0

q-SOFA= 2 out of 3 points: bp<100mm/hg; rr> 22 breaths/min; GCS< 15*”The Consensus” opinion specifically only applies to people over the age of 18

3

The Problem of SepsisOTHER SYMPTOMS

Extreme pain or general discomfort Sleepiness Shortness of breath Rash Nausea and vomiting Clammy or sweaty skin

Labso Elevated C-Reactive Protein (CRP)(>10 mg/L)o Elevated Procalcitonin (>.15ng/mL)o Elevated Mature Neutrophils (>7,000 permm^3)(Neonatal Sepsis: Low Absolute Neutrophil counts)o Lymphocytosis (>40% of WBC or >4,500 per

mm^3)o Eosinophilia (> 500 eosinophils/mL)

https://www.cdc.gov/sepsis/signs-symptoms.html

The Problem of Sepsis

Prevalence Cost Conflicting Medical Definitions

The high cost of Sepsis and its increased prevalence incentivizes CMS and private payers to focus on decreasing reimbursement for patients with Sepsis. Citing conflicting medical definitions is often the reason used.

Achieving Sepsis Reimbursement

With a focused effort by all departments from Admission to Discharge and beyond,

reimbursement for healthcare costs from Sepsis and incentives for excellent treatment of Sepsis

can be obtained! It is even possible to earn incentives on top of full payment.

Achieving Sepsis Reimbursement

Coding of Sepsis is accurate and compliant when:

There is Documentation of “Sepsis,” “ Severe Sepsis” or “Septic Shock” andDocumentation is Clear and Consistent, and Documentation identifies a Source of Infection, andDocumentation identifies that Sepsis is related to the source infection

(Note – no ICD-10 requirement for the Coder to assess)

Achieving Sepsis Reimbursement

Accurate ICD-10 Coding of Sepsis(It’s not all the Coder’s fault)

Coding of Sepsis is accurate and compliant when:Documentation of “Sepsis, Severe Sepsis or Septic Shock” is specified and Documentation is Clear and Consistent

Not enough to code Sepsis:

• “Bacteremia” Which is a symptom (R78.81) of Sepsis meaning blood cultures positive for infection that may not be separately coded if you are coding Sepsis

• “Septicemia” No ICD-10 Code for this term, including Sepsis• “Urosepsis, “ nonspecific term with no default code in alphabetic index• “SIRS” alone Which is a symptom code (R65.1) which can be of infectious or noninfectious origin.• “Septic, Toxic” alone These are adjectives, not diagnoses and are akin to “infectious”• “History of Sepsis” alone Be careful when Sepsis is only documented this way• “Sepsis ruled out” Not the same as R/O Sepsis

Achieving Sepsis Reimbursement

Coding of Sepsis(Still not all the Coder’s fault)

Coding of Sepsis is accurate and compliant when:

There is Documentation of “Sepsis, Severe Sepsis or Septic Shock” and there is an identified Source Infection and an associated systemic response.

• AHA Coding Clinic Fourth Quarter 2016 p.147 states“Coding must be based on provider documentation . . . Only the physician or other qualified healthcare practitioner legallyaccountable for establishing the patient’s diagnosis, can ‘diagnose’ the patient.”

• AHA Coding Clinic Fourth Quarter 2017 p.98 states,“The Guidelines state that a code is assigned when the provider documents sepsis and an associated acute organ dysfunction.”

Achieving Sepsis Reimbursement

Coding of Sepsis

Question: “We have recently seen the issued consensus definitions for sepsis and septic shock. How and when will this affect the codingof Sepsis and Septic Shock for ICD-10-CM? Will the cooperating Parties be modifying the coding guidelines because of the new clinicalguidelines for sepsis?

Answer: “The Coding Guidelines are based on the ICD-10-CM classification as it exists today. Continue to code sepsis, severe sepsis andseptic shock using the most current version of the ICD-10-CM classification and the ICD-10-CM Official Guidelines for Coding andReporting. Code assignment is based on provider documentation (regardless of the clinical criteria the provider used to arrive at thediagnosis.)

Quality Assurance, CDI and the Facility should be aware that when the coder sees an uncontested Physician’s diagnosis of Sepsis withassociated source infection, it is the coder’s job to Code the appropriate Sepsis Code to achieve reimbursement for Sepsis care. TheCoder is not permitted to choose to Undercode.

What the Facility and CDI can do is isolate codes that are at high risk for post payment reduction and for those cases require:

Correlation with Quality Assurance

CDI review for sufficiency of documentation

Achieving Sepsis ReimbursementAHA Coding Clinic 3rd Quarter 2016, p. 8 states:

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)d. Sepsis, Severe Sepsis, and Septic Shock

1) Coding of Sepsis and Severe Sepsis(a) SepsisFor a diagnosis of Sepsis assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis unspecified organism.

A code for subcategory R65.2X, Severe Sepsis, should not be assigned unless severe sepsis or an associated organ dysfunction is documented.

(and ICD-10-CM Section I.B.18: Only when “sufficient clinical information isn’t known or available about a particular condition it is acceptable to report the appropriate “unspecified” code.”)

72% of the time A41.9, Unspecified Sepsis is used to code Sepsis. Coders should look further to see if a more specified code can be supported.

If “Severe Sepsis” is supported and Septic Shock is present, the Coder is apt to add R65.21 (Severe Sepsis with Septic Shock which is an MCC) but if the Severe Sepsis Organ Failure is not Shock, R65.20 (Severe Sepsis without Septic Shock which is neither MCC nor CC) is often not coded – this is a flag to payers to evaluate for Denial.

Achieving Sepsis ReimbursementICD-10-CM Official Coding Guidelines:

A40.0 Sepsis due to Streptococcus AA40.1 Sepsis due to Streptococcus Group BA40.3 Sepsis due to Streptococcus Group PneumoniaeA40.8 Other Streptococcal SepsisA40.9 Streptococcal Sepsis, UnspecifiedA41.01 Sepsis due to MSSAA41.02 Sepsis due to MRSAA41.1 Sepsis due to Other specified StaphylococcusA41.2 Sepsis due to Unspecified StaphylococcusA41.3 Sepsis due to Hemophilus InfluenzaeA41.4 Sepsis due to AnaerobesA41.50 Gram Negative Sepsis, UnspecifiedA41.51 Sepsis due to Escherichia Coli [E. Coli]A41.52 Sepsis due to PseudomonasA41.53 Sepsis due to Serratia

Achieving Sepsis ReimbursementICD-10-CM Sepsis Codes (FY 2019)

A41.59 Other Gram-Negative SepsisA41.81 Sepsis due to EnterococcusA41.89 Other Specified Sepsis (Viral Sepsis)\P36.10 Sepsis of Newborn due to Unspecified StreptococcusP36.19 Sepsis of Newborn due to Other Streptococcus P36.2 Sepsis of Newborn due to Staphylococcus AureusP36.30 Sepsis of Newborn due to Unspecified Staphylococci P36.1 Sepsis of Newborn due to Other StaphylococciP36.4 Sepsis of Newborn due to Escherichia ColiP36.5 Sepsis of Newborn due to AnaerobesP36.8 Other Bacterial Sepsis of NewbornP36.9 Bacterial Sepsis of Newborn, Unspecified

R65.20 Severe Sepsis without Septic Shock(R65.10 SIRS without organ dysfunction)R65.21 Severe Sepsis with Septic Shock(R65.11 SIRS with organ dysfunction)

T81.12 Postprocedural Septic Shock, Initial EncounterT81.4 Infection following a Procedure (includes “Sepsis following a procedure”)

CMS and HHS HCC 2 – Septicemia, Sepsis, SIRS, Shock

When Documentation is Conflicting, the Coder should not give up on the Sepsis Diagnosis, but should be given to a CDI for Query.

AHA Coding Clinic First Quarter 2004 pp. 18 – 19“Code assignment may be based on other physicians’ (ie. Consultants, residents, anesthesiologists, etc.) documentation as long as there is no conflicting information from the attending physician”

When there is conflicting documentation, a code cannot be assigned until resolved by a query.

Be aware that the following is a “conflicting Diagnosis” that requires a query for documentation clarification. If the attending diagnoses “Sepsis” and the ID Consultant diagnoses “Other Gram Negative Sepsis” AHA Coding Clinic Fourth Quarter 2004 pp 77-78 suggests a query is necessary to confirm the specification.

Achieving Sepsis Reimbursement

“Negative or inconclusive blood cultures do not preclude a diagnosis of Sepsis in patients with clinical evidence of the condition, however the provider should be queried.”

When there is a negative blood culture the Coder should forward the case to CDI for improved documentation.

Achieving Sepsis ReimbursementICD-10-CM Official Coding Guidelines I.C.1.d.1.a.i states

“Negative or inconclusive blood cultures do not preclude a diagnosis of Sepsis in patients with clinical evidence of the condition, however the provider should be queried.”

When there is a negative blood culture the Coder should forward the case to CDI for improved documentation.

Achieving Sepsis ReimbursementICD-10-CM Official Coding Guidelines I.C.1.d.1.a.i states

Remember – under any of the 3 standards validating Sepsis, these definitions ALL require a Provider’s diagnosis of Sepsis and a Provider’s diagnosis of an associated response beyond the symptoms of local infection.

A Local Infection without documented language linking the Infection to Sepsis cannot be the basis for a Sepsis code.When there is no linking language, the Coder should forward the case to CDI for improved documentation.

Achieving Sepsis ReimbursementThe most

common cause of Sepsis is

Pneumonia followed by UTI

Due toAssociated with WithRelated toCaused byCausing From

ICD-10-CM Official Coding Guidelines Section I.C.1.d.4 states:

“If the reason for admission is both Sepsis or Severe Sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis.”

In most (but not all) cases, Sepsis will be the Principal Diagnosis when POA

If POA Status of the Sepsis diagnosis is not clear, the Coder must give the case to the CDI for clarification of documentation.

Sepsis POA has increased the most, possibly due to emphasis on early detection, and comprises 86.8% of reported Sepsis cases.

Achieving Sepsis ReimbursementTHE IMPORTANCE OF POA STATUS

ICD-10-CM Z91.1_ is accurately coded when the patient is “noncompliant with other medical treatment or regimen.”

The accurate presence of a Noncompliance Code does not provide a CC or an MCC but may allow exemption from SEP-1 Core Measure consequences and certain Value Based consequences.

Achieving Sepsis Reimbursement

A Coder correctly codes Sepsis or Severe Sepsis or Septic Shock when the diagnosis is documented, specified and related to its source infection, and note:

no requirement claims data match Quality reporting and no ICD-10 or specific CMS requirement for the Coder to assess Clinical Validation

BUTWill the cost of the care you provided be reimbursed?Will you be penalized with additional payment reductions?

The Facility can require more of the coder when coding these diagnoses, such as querying for more documentation and or referring case to a CDI.

HOSPITALS ACROSS THE COUNTRY LOSE $262 BILLION per year on DENIED CLAIMS

Achieving Sepsis Reimbursement

Protecting Sepsis Reimbursement

The Main Role of CDI is to ensure that accurate documentation exists in the medical record to support coded (claims) and quality data

In Sepsis cases, the CDI is challenged as to what documentation , under which Sepsis standard needs to be present to support Sepsis codes.

The best practice for CDI is to know each of the 3 standards and try to ensure that all clinical indicators present under each definition are documented.

Protecting Sepsis ReimbursementCLINICAL DOCUMENTATION IMPROVEMENT

Clarifying diagnostic language Lack of language linking source infection to Sepsis(Septicemia, Urosepsis, etc.) Lack of language linking organ damage

to Severe Sepsis +/or Septic ShockSpecification of diagnosis

(i.e. Other Gram Negative Sepsis) Lack of identified source infection(i.e. Severe Sepsis, Septic Shock)

Conflicting diagnoses Lack of positive blood cultures

When writing a Sepsis Query, make sure to include Clinical Indicators of Sepsis that are actually present under all three criteria in the facts section of the query.

Protecting Sepsis ReimbursementICD-10-CM REQUIREMENTS FOR CDI DOCUMENTATION ASSESSMENT AND POSSIBLE SEPSIS QUERY

Clinical indicators Query adding Clinical indicators Query when documentedSIRS/SOFA indicators. Clinical Indicators are absent, including

Ruled-out SepsisSolo Sepsis diagnosis, especiallyin ED, D/C Summary Verification of Complication Diagnosis, for

consistency in Claims and Quality Data POA status of Sepsis

Sepsis Protocol or Bundle Verification of reasoning for provided without clear special circumstancesSepsis diagnosis.

When writing a Sepsis Query, make sure to include Clinical Indicators of Sepsis that are actually present under all three criteria in the facts section of the query.

Protecting Sepsis ReimbursementSOME CIRCUMSTANCES SUGGESTING CDI DOCUMENTATION ASSESSMENT AND POSSIBLE QUERY TO PREVENT DENIALS AND POST-PAYMENT PENALTIES.

By submitting this query we are seeking further clarification of documentation to accurately reflect all conditions you are monitoring, evaluating, treating or that extend the hospitalization or utilize additional resources of care. Please utilize your independent judgement when addressing the questions below on this form which is part of the medical record.

The medical record includes the following information:

• “Mr. W was admitted with Pneumonia.”• xx/yy Emergency Department: Dr. ZZ Final Impression “Sepsis Likely 2/2 Pneumonia”• The Diagnosis of Sepsis is not included elsewhere in the Medical Record.• xx/yy Emergency Department: SEP-1 Sepsis Protocol labs and treatment initiated at 3 and 6 hours including administration of crystalloid

fluids and Intravenous Antibiotics and laboratory blood cultures drawn twice and returned “negative for the presence of micro-organisms.” “Patient was nauseous and weak.” Procalcitonin 0,22 ng/ml.

• xx/yy SIRS and SOFA Criteria: Heart Rate 110 b/min, Respiratory Rate 32 breaths/min, Bands 15%, GCS in EMS 13, Lactate 2.1.

Protecting Sepsis ReimbursementExample of including Clinical Indicators of Sepsis that are actually present under all three criteria in the facts section of the query.

One function of the Quality Assurance department is to report Quality Assurance Data to CMS and to “All-Payer Claims Databases.”-Value-Based Care payment adjustments are based, in part on this data-Hospital Compare Leapfrog and Healthgrades, Public Reporting are based on this data-Other Incentive Payment Programs are based on this data

For Example, -if the physician documented postprocedural sepsis not as a condition but as a timestamp, -and Coding realized this and did not code T81.12XA -and CDI clarified this fact by Query reply-but Quality Assurance reported the incidence of Postprocedural Sepsis to the Quality Payer Databases, reimbursement for the

Sepsis Case may be diminished by inaccurate

CDI need to make sure matching Quality and Claims Data based on the same documentation is sent. CDI may need to obtain clarified documentation to support Quality indicators.

http://www.ncsl.org/research/health/collecting-health-data-all-payer-claims-database.aspxhttps://www.medicare.gov/hospitalcompare/Data/Measure-groups.html

Protecting Sepsis ReimbursementTo Optimize a Focused Consistent Approach to achieve and protect reimbursement for Sepsis care, CDI and Quality Assurance must work together to provide consistent Quality and Claims Data

First Hospital Compare 2015 showed the national average compliance rate for the CMS'

sepsis treatment as 49%.

Often, Sepsis claims are denied without any reason given.

When a reason is given these are most common:

“Lack of documented clinical indicators”“insufficiently supported” “no clinical validation”“there was no evidence that the patient’s symptoms were due to any localized infection”“We acknowledge the condition as documented but don’t think this was a valid diagnosis.”“There was no evidence of dysregulated response to infection”“Clinical Indicators needed to validate the current standard for Sepsis were lacking”

To protect a claim from post-payment reduction, CDI may have to query for documentation beyond the normal standard.

Protecting Sepsis ReimbursementDENIALS MANAGEMENT

UnitedHealthcare Adopts Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) and Supports the Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock

Effective Jan. 1, 2019, Sepsis-3 will be used as part of UnitedHealthcare’s clinical claim reviews to validate that sepsis was present and sepsis treatment services were appropriately submitted as part of the member’s claim. Hospital payments will be adjusted if UnitedHealthcare determines, after reviewing the member’s medical record and Sepsis-3, that sepsis was not present and sepsis treatment services should not have been included as part of the member’s claim. Sepsis-3 will be used for all UnitedHealthcare benefit plans including commercial, Medicare Advantage and Medicaid plans.

UnitedHealthcare Adopts Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) and Supports the Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock Effective Jan. 1, 2019, Sepsis-3 will be used as part of UnitedHealthcare’s clinical claim reviews to validate that sepsis was present and sepsis treatment services were appropriately submitted as part of the member’s claim. Hospital payments will be adjusted if UnitedHealthcare determines, after reviewing the member’s medical record and Sepsis-3, that sepsis was not present and sepsis treatment services should not have been included as part of the member’s claim. Sepsis-3 will be used for all UnitedHealthcare benefit plans including commercial, Medicare Advantage and Medicaid plans.

https://acdis.org/articles/news-unitedhealthcare-adopts-sepsis-3-criteria-claims-validation

Protecting Sepsis ReimbursementDENIALS MANAGEMENT

1. Identify Sepsis issues and the specific way they impact the Facility.Prevalence:

Community DemographicsPayer MixClaims and Quality Reporting DataCBR Report and BenchmarksPEPPER Report

CostHCRISCompare reporting, Leapfrog and Healthgrades ReportingPayor Contracts

Conflicting medical definitionsMedical Staff criteria for diagnosing Sepsis Management of SEP-1 reporting

Protecting Sepsis ReimbursementDENIALS MANAGEMENT 1/3

To recoup maximal sepsis reimbursement, the Facility must:

The average LOS is 75% longer for sepsis patients

2. Take a consistent, system-wide approach, planned and managed by a Sepsis Team with members from:

Medicine and NursingLaboratory and PharmacyBilling and AdmittingCoding, Quality, Utilization Review and Case Management.

3. Implement Policies & Procedures to ensure consistent treatment and documentation of SepsisDevelopment of forms (that include SIRS, SOFA and SEP-1 terms)Ensure consistent release of Claims and Quality dataTake action to prevent Sepsis Readmissions

Protecting Sepsis ReimbursementDENIALS MANAGEMENT 2/3

To recoup maximal sepsis reimbursement, the Facility must:The average cost per case for hospital-associated sepsis jumped from @ $58,000 in 10/2015 to @ $70,000 in 9/2018. Patients who developed sepsis in the hospital were 10% more likely to have septic shock than those with sepsis upon admission

4. Make a plan to minimize ReadmissionAssess likelihood of obtaining medication access and follow-up treatment accessAssess ability of discharge facility and/or caregivers to comply with follow-up treatment.Scrutinize quality and claims date representing Readmissions for Sepsis

5. Make a plan to minimize Post-Payment reductionsDenials – Optimize DocumentationSEP-1 – Optimize reportingValue Based and HRRP reductions – scrutinize documentation and reporting for poa status and presence of noncompliance coding or other exemptions from bundlingMetrics analysis to improve gaps in Sepsis care

Protecting Sepsis ReimbursementDENIALS MANAGEMENT 3/3

To recoup maximal sepsis reimbursement, the Facility must:

Estimated cost of Sepsis Readmissions in the US is >$3.5 billion annually (>AMI, CHF COPD, and PNA COMBINED)

HRRP Reductions in CMS Base Rate increased to $528 million in 2017

Scenarios

Ms. W is a 39 year old woman who has a 1 and a ½ year old child whom she is breastfeeding. She is a Type I Diabetic. She has no other Chronic Conditions. One month prior to her admission she developed a painful reddened area on her left breast. Her left breast became reddened and inflamed and she developed a fever. She contacted her physician who prescribed an oral antibiotic. Ms. W’s condition worsened and she became weak and nauseous. She stopped eating and drinking. On XX/YYYY Ms. W fainted while grocery shopping and was brought to the ED by ambulance. In the ambulance EMS noted Ms. W’s blood glucose was normal. EMS noted Ms. W. had a temperature of 101.1. EMS gave a bolus of NS. EMS noted Ms. W.’s GCS was 12 when they arrived (as she was disoriented and unable to speak clearly) and improved to 15 by the time they reached the ED.

In the ED MS. W’s vital signs included: T. 100.0, HR 110, RR 22 MS. W’s laboratory results included: Lactate 2.1, WBC 11, Procalcitonin 0.21 Creatinine 1.8ED physician documented: Final Impression – Mastitis, R/O Sepsis, possibly severe, AKI v. Renal Insufficiency possibly due to dehydration/infection ED physician ordered “Sepsis Protocol” and Ms. W. began receiving > 30ml/kg NS and IV Dicloxacillin and Cephalexin which she received throughout admission.

Ms. W. remained hospitalized for 4.5 days and recovered well. All other providers in the Medical Record documented only a diagnosis of Mastitis. Blood Cultures x 2 both returned negative for microorganisms.

ScenariosScenario 1

The Facility realized Sepsis is a diagnosis prevalent in their community and a diagnosis where their publicly reported quality statistics are not favorable. Also, they examined reports such as their HCRIS report, Denials and readmission dateand realized the likelihood was that they would not receive full reimbursement on any Sepsis case, and were losing money as well.

A Sepsis Team was developedFacility Forms were reviewed and revised to capture maximal Sepsis documentation under all three Clinical Sepsis definitionsQuality designated individuals to perform Sepsis Abstraction, monitor use of Sepsis Bundles and coordinate with CDI to send consistent Quality and Claims data.

The Coder provisionally coded A41.9, Sepsis Unspecified, and N61.1 for Mastitis /Abscess of Breast and N17.9 AKI, Dehydration and R65.20 for Severe Sepsis without Septic Shock.

The Coder realized that this case is at high risk for reduced payment and for Denial on Postpayment review, so the Coder refered this case to CDI for documentation analysis.

ScenariosScenario 1

The Quality Assurance team has designated an employee for monitoring and abstraction of Severe Sepsis. The QA individual checks the timely completion of the Sepsis Bundles noting Sepsis was diagnosed POAThe QA individual checks the results of the Coding/CDI work to ensure that Quality data are being released consistent with Claims Data.

The CDI realized this case is at high risk for reduction in payment due to lacking documentationUsing SEP-1 protocols and raised lactate and SIRS heart rate, fever (in EMS) respiratory rate, creatinine and mental status (GCS in EMS) and SOFA creatinine elevation and GCS reduction in the Query summary of facts, the CDI will query for:

Sepsis and Severe Sepsis Diagnosis Presence of AKI and whether AKI in whole or part was due to Sepsis.

ScenariosScenario 1

Mr. B. is a SNF resident. He has a history of Atrial Fibrillation, COPD, Alzheimer's Dementia and CVA with residual mild Dysphagia. Two days before this admission Mr. B. was witnessed to choke on his pureed lunch. Since that time he developed a worsening cough productive of green sputum. He was brought to the hospital when he became short of breath. His Respiratory rate was 32 and he was placed on 2L of Oxygen by NC. Oxygen. He is a DNR/DNI statusIn the ED Mr. B’s vital signs included: T. 100.8, HR 110 and irregular, RR 32

Mr. B’s laboratory results included: WBC 11, normal lactate and electrolytes and the Mr. B. was very agitated so an ABG was“deferred.”

Mr. B.’s EKG showed Atrial FibrillationMr. B’s Chest X-ray confirmed “Right Upper Lobe Pneumonia”

ED physician documented: Final Impression – Pneumonia, Possible Early Sepsis,Respiratory InsufficiencyED physician ordered IV Levaquin.

In the rest of the Medical Record, Sepsis is not documented. Pneumonia is documented. Acute Respiratory Failure is documented. Blood Cultures were Negative x 2.

ScenariosScenario 2

The Facility realized Sepsis is a diagnosis prevalent in their community and a diagnosis where their publicly reported quality statistics are not favorable. Also, they examined reports such as their HCRIS report, Denials and readmission dateand realized the likelihood was that they would not receive full reimbursement on any Sepsis case, and were losing money as well.

A Sepsis Team was developedFacility Forms were reviewed and revised to capture maximal Sepsis documentation under all three Clinical Sepsis definitionsQuality designated individuals to perform Sepsis Abstraction, monitor use of Sepsis Bundles and coordinate with CDI to send

consistent Quality and Claims data.

The Coder concurrently coded Sepsis A41.9 but then removed the Sepsis code and made Lobar Pneumonia J18.1 the Principal Diagnosis.

The Coder referred the case to CDI for evaluation of solo MCC Acute Respiratory FailureThe Coder coded Lobar Pneumonia so the HCC could be captured, maximizing Value Based Payment Opportunities and the patient’s PCP

ScenariosScenario 2

The Quality Assurance team has designated an employee for monitoring and abstraction of Severe Sepsis but in this case only Sepsis is documented and there are no complication codes so Quality would not be involved.

CDI reviews the Medical Record and assesses for a Sepsis diagnosis as well. CDI agrees with Coder that there is insufficient evidence in the medical record for Coding or Query for Sepsis.

Severe Sepsis is not documented so there is no requirement to abstract or analyze Quality. None of the 3 Sepsis definitions are met by the current documentation because

While the Source infection is identified, there is no linking of the source infection to any organ failure/dysregulated response/SepsisThe diagnosis of Sepsis is inadequately documented and blood cultures were negative so a query would be required to code Sepsis.While Mr. B. has individual SIRS and SOFA Criteria, there is no documented evidence to disprove that these symptoms were not associated with Mr. B.’s Chronic Conditions and/or Acute Pneumonia. While a query could be sent for this weakness alone, it is questionable whether there is enough evidence of Sepsis on which to base a compliant query.

ScenariosScenario 2

Mr. S. is Homeless. He was found moaning on the street and brought to the Emergency Department. In the ED Mr. S.’s vital signs included: T. 96, HR 58, RR 20, BP 70/30.

Mr. S’s laboratory results included: Lactate 4.1, WBC 19, Procalcitonin 0.21 Creatinine 2.1Mr. S.’s Chest X-ray confirms Pneumonia and his urine is bloody with the presence of RBCs and WBCs. CT confirms Pyelonephritis.Mr. S. also has several small but deep skin wounds.ED physician documented: Final Impression –Likely Sepsis of unknown origin with Septic Shock, Pneumonia, AKI, Pyelonephritis, Skin Wounds.ED physician ordered “Sepsis Protocol” which was performed at 3 and 7 hours of admission because he had pulled out his IV

in attempt to leave the hospital and Mr. S. began receiving > 30ml/kg NS and IV Nafcillin and Cefotaxime throughout admission. Physical examination and evaluation of Septic Shock was

performed at 7 hours after Mr. S.’s noncompliance was addressed. Mr. S. also received a short dose of IV Levophed to which his blood pressure responded well. Blood Cultures were + for Gram Negative RodsMr. S. remained hospitalized for 7 days. The Attending Physician diagnosed “Sepsis” and the Infectious Disease specialist documented “Sepsis due to Gram Negative Rods in Urinary Tract Infection.”

ScenariosScenario 3

The Facility realized Sepsis is a diagnosis prevalent in their community and a diagnosis where their publicly reported quality statistics are not favorable. Also, they examined reports such as their HCRIS report, Denials and readmission dateand realized the likelihood was that they would not receive full reimbursement on any Sepsis case, and were losing money as well.

A Sepsis Team was developedFacility Forms were reviewed and revised to capture maximal Sepsis documentation under all three Clinical Sepsis definitionsQuality designated individuals to perform Sepsis Abstraction, monitor use of Sepsis Bundles and coordinate with CDI to send

consistent Quality and Claims data.

The Coder coded Other Gram Negative Sepsis A41.59 as well as R65.21, Sepsis with Septic Shock and Z 91.19 for Noncompliance.

The Coder referred the case to CDI for evaluation of coordination with Quality metrics and for evaluation of need for “Severe Sepsis” documentation.

ScenariosScenario 3

The Quality Assurance team has designated an employee for monitoring and abstraction of Severe Sepsis. In this case Sepsis Shock was documented; clinical indicators for Sepsis with Shock were present under SEP-1 SIRS criteria but the patient did not receive his 2nd evaluation within the 6 hour time window.

QA sees there is documentation and coding of the Noncompliance delaying the second evaluation which exempts the case from theSEP-1 Quality reporting such that Mr. B’s case will not result in an inappropriate care statistic on the Compare website.

CDI reviews the Medical Record and assesses the Sepsis diagnosis. CDI agrees with the Coding profile but feels the case may be protected from Denial if a query is sent verifying Severe Sepsis with facts iterated in the fact section specifically including SIRS and SEPSIS criteria.

ScenariosScenario 3

Q & A

Implement a Facility-wide, focused, organized approach to Sepsis

Key Takeaways

Coders – It is rarely the Coder’s Fault!

• Code specified Sepsis Codes when possible• Refer to CDI when directed by ICD-10 or

when there is missing or conflicting documentation or as directed by Facility

• Include codes for Severe Sepsis when applicable regardless of Case Mix impact

• Include codes for Noncompliance regardless of Case Mix Index.

CDI – Improve Documentation to Achieve Reimbursement and to Protect Reimbursement

• Coordinate with Quality Assurance to obtain consistent Quality and Claims Data

• Be Familiar with and include indicators under all three definitions of Sepsis in Factual Portion of Query

• Be aware of individual Payer standards and Local Law requirements when Querying