Clinical reality, the ICD-10-CM classification system, and considerations of reimbursement are three distinct worlds that are sometimes in conflict. We don’t like it when financial considerations intrude on the purity of coding, but there’s no escaping this intrusion when coding serves as both the representation of the clinical picture in healthcare data and as the basis for reimbursement.
Sepsis Definitions at Odds
Sepsis provides a great illustration of a coding gray area that can undermine healthcare data. Since JAMA published the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) in February of 2016, the US healthcare community has been divided on the use of the new definition of sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” This division has been sharpened by the decision of CMS not to adopt the Sepsis-3 definition, and to keep their long-established definition of sepsis as Systemic Inflammatory Response Syndrome (SIRS) due to an infection.
The Sepsis-3 task force recommends the Sequential Organ Failure Assessment (SOFA) score to measure the organ dysfunction inherent in the new definition. The score incorporates lab values and other clinical indicators that reveal damage or impending damage to end organs in different body systems. Patients with a score of 2 or greater (assuming a baseline score of zero) can be clinically characterized as septic.
The SIRS-based definition, originally developed in 1991, rests on abnormal values in four categories: heart rate (>90), temperature (>38C or <36C), white blood cell count (>12K or <4K), and respiratory rate (>20 per minute). While some additional diagnostic criteria were added in 2001, these four pillars of SIRS have been known to clinicians and coders for decades. By this definition, a patient with a proven or suspected infection who exhibits two or more of these criteria can be clinically characterized as septic.
Take a patient with a urinary tract infection, fever of 100.5, and white count at 12.1K, who is admitted to a regular bed, given IV antibiotics, and discharged home in a day or two. Using a SIRS-based definition, this patient could be considered “septic.” Was this truly a life-threatening systemic infection? Does reporting the encounter as sepsis accurately capture the stay? Is it correct for the claim to pay significantly more than the cost of a “normal” stay for a urinary tract infection? As auditors, with many years of coding and clinical validation behind us, we have always thought the answer to all these questions is: seems unlikely; let’s look at the record!
One obvious downside to using SIRS criteria is that we risk overstating the number of sepsis cases and our success in treating them. If at least one third of the cases reported as sepsis are not clinically valid (my informal and very conservative estimate), then the mortality statistics based on those stays are skewed. Are we really doing a better job of managing these patients? Are the truly septic patients faring any better than they were ten years ago? Part of the CMS rationale for sticking with SIRS, besides familiarity, is that sepsis mortality rates have been continuously falling, and a change to the sepsis definition could threaten that progress.
A 2017 study in JAMA looking at data from 409 acute care inpatient stays between 2009 and 2014 found that using claims data (i.e. – coded claims) vs. clinical data from the EHR painted two different pictures of sepsis incidence and outcomes. Instead of significantly rising sepsis cases and lower mortality rates indicated by the claim review, the study found that using SOFA-based clinical criteria to identify sepsis showed both the number of sepsis cases and their associated death rate to be stable from 2009 to 2014.
The elephant in the room is that hospitals have a financial incentive to use SIRS criteria because a reported diagnosis of sepsis on a DRG-paid claim often results in higher (sometimes significantly higher) reimbursement than a similar claim for a localized infection. If a source as authoritative as CMS endorses using SIRS, how is it fair to facilities that sepsis is being removed by auditors based on a completely different set of criteria?
In my experience as an auditor, providers fighting SOFA denials often argue that CMS-approved SIRS criteria were met and that sepsis involving organ failure (i.e. – “severe sepsis”) was prevented from developing by prompt, aggressive care which was more intense than would normally be given for a localized infection. They don’t like feeling as if they’re being penalized for providing good care simply because some people have adopted a different definition of sepsis. As compelling as that argument might be, if the payor explicitly supports the use of the Sepsis-3 definition, the provider’s appeal will not be successful, and the two sides will have to agree to disagree.
The reason for the impasse is twofold. First, we are using what were designed to be clinical screening and prognostication tools as permission to code—a tendency that has been reinforced by the CDI process. I absolutely did it myself in the early CDI days. If we were working a case with a local infection and found two SIRS criteria met, we’d be considered negligent if we didn’t query the physician for sepsis. Clinically speaking, though, a patient at risk for developing sepsis is not the same as a patient with sepsis. This brings me to the second reason for the impasse: ICD-10-CM doesn’t provide us with any alternative codes or guidelines. If sepsis is prevented from evolving, then it is the same to a coder as having been “ruled out.”
Do We Need a New Code?
Without overstating our sepsis cases, how can we fairly and accurately track data and compensate facilities when they’ve truly used additional resources to prevent sepsis from developing? Would it help to have an entry for “impending sepsis”—a new diagnosis code in the Symptom chapter that would serve as a CC or MCC? What would the clinical criteria look like for such a code? Would adding this code help bridge the gap between the clinical picture, the requirements of coding, and the reimbursement that hospitals depend on to keep serving patients?
About Chris Gallagher
Chris Gallagher CCS, CDIP, is VP of Delivery at Penstock, a payment integrity, and reimbursement consulting company. Penstock is an affiliate of Goodroot, a community of companies committed to lowering healthcare costs and increasing access to quality care by reinventing healthcare one system at a time.
Singer M, Deutschman CS, Seymour CW, 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.
Townsend SR, Rivers E, Tefera L. Definitions for Sepsis and Septic Shock. JAMA. 2016;316(4):457–458. doi:10.1001/jama.2016.6374.
Levy, Fink, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med (2003) 29:530–538. DOI 10.1007/s00134-003-1662-x.
Rhee, Dante, et al. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014 JAMA. 2017;318(13):1241-1249. doi:10.1001/jama.2017.13836 Published online September 13, 2017.
Tidswell, R, Inada-Kim, M, and Singer, M. Sepsis: The Importance of an Accurate Final Diagnosis. Lancet Respir Med. 2020 Nov 2:S2213-2600(20)30520-8. doi: 10.1016/S2213-2600(20)30520-8. Epub ahead of print. PMID: 33152272.