Volume 20, Issue 3

Current Challenges in Sepsis Documentation and Coding: A Review of the Literature

By Jaime Sand, EdD, RHIA, CCS, CAHIMS and Alba Kuqi, MD, MSHIM

Abstract

Sepsis has continued to climb the charts as one of the most frequent principal diagnoses for hospitalizations in the US and one of the most expensive conditions to treat in the nation’s hospitals. It is unsurprising that it warrants additional scrutiny by payers and also remains one of the most frequently denied diagnoses. Challenges arise in sepsis billing due to the variety of definitions of the condition and changing clinical indicators impacting documentation and coding. This article reviews the literature related to the diagnosis, documentation, coding, and billing of sepsis since the more widespread implementation of the Sepsis-3 definition in 2017 to outline the challenges and recommendations discussed by industry leaders. Addressing accurate sepsis diagnosis and reimbursement relies on clear organizational policies, accurate and helpful tools, education and training, and consistent denial management.

Keywords: sepsis, septicemia, coding, denials, CDI

Introduction

Sepsis has been recognized as a leading cause of death and significant financial burden with incidence increasing annually, with some claiming that it may still be underrecognized and underreported.¹ This may be due, in part, to the lack of a universal clinical definition, challenges in coding sepsis, and regular denials of sepsis on claims.² The clinical criteria remain complicated and ambiguous, without clear biological, imaging, or laboratory features to uniquely identify a septic patient.³ Septicemia or severe sepsis with a major complication, Medicare Severity Diagnosis Related Group (MS-DRG) 871, was the most frequently billed MS-DRG in FY 2019, leading many payers to scrutinize sepsis-related claims, reviewing them both prepayment and post-payment.⁴ There are increasing clinical validation denials due to misaligned sepsis criteria between providers and payers, a lack of clinical indicators and/or documentation, and the additional focus on these types of claims. Denials are expensive and resource-intensive, and inaccurate coding of sepsis in claims data may negatively impact funding and accurate epidemiological representation.⁵

A Rising Problem

It is clear that the challenge of diagnosing, treating, and billing sepsis are not going away, as the number of sepsis-related admissions and claims continue to rise. Table 1 shows the number of discharges and associated average charges and payments from Medicare inpatient hospitals in 2020, both nationally and within the highest and lowest states. This highlights the increasing number of discharges and the wide range in average submitted charge.

The Healthcare Cost and Utilization Project (HCUP) has further highlighted the burden of sepsis-related admissions and claims amongst all payers. Septicemia was the most frequent principal diagnosis for hospitalizations in the United States in 2018 with 2,218,800 stays representing eight percent of nonmaternal, nonneonatal inpatient stays.⁶ This number more than doubled in seven years, with just over one million discharges indicated in 2011.⁷ Sepsis also remained the most expensive condition treated in U.S. hospitals, costing $41.5 billion in aggregate and averaging $18,700 per stay.⁸ This was up from $38.2 billion (8.8 percent of national costs) in 2017, $23.6 billion (6.2 percent) in 2013, and $20.3 billion (5.2 percent) in 2011.^9,10,11 Cost was highest in the West and lower in the Midwest and South.¹²

Part of this cost may be associated with the high use of the intensive care unit (ICU) for patients diagnosed with sepsis. In 2011, HCUP indicated that MS-DRG 871 was among the most common conditions with the highest proportion of ICU utilization in 29 states at 59 percent. Those without a major complication or comorbidity, MS-DRG 872, were at 27.5 percent.¹³ A 2012 statistical brief from HCUP that highlighted super-utilizers, those individuals who consume a large share of health care resources, indicated that septicemia was amongst the 10 most common principal diagnoses for these patients across all payers.¹⁴ It was also among the top 10 conditions with discharges to post acute care (PAC) in 2013, with MS-DRGs 870-872 accounting for 441,400 discharges to PAC (39.4 percent) with the most going to skilled nursing facilities (53.5 percent).¹⁵ Septicemia also accounts for a large portion of readmissions. In 2014, septicemia ranked among the top 20 diagnoses with the highest 7-day (6.7 percent) and 30-day (18.5 percent) readmission rates.¹⁶ This was confirmed again in 2018 when hospital stays for septicemia had the highest number of 30-day all-cause readmissions at 314,600 (accounting for 8.3 percent of all readmissions).¹⁷

In addition to high cost, septicemia is of particular concern for certain vulnerable populations. According to the 2018 HCUP data, rural areas had the highest rate of stays for septicemia but decreased mean length of stay and cost per stay.¹⁸ A 2014 study showed that septicemia was more than 10 times higher among those aged 75+ years than those aged 18 to 44 years, making it the most common diagnosis among that age group (7.6 percent).¹⁹ It was also found that among patients readmitted within 30 days of an index stay for septicemia, uninsured patients were more likely than patients with insurance to return within 7 days.²⁰ In 2018, average readmission costs were highest amongst the self-pay/no charge patients and those with Medicaid accounting for 8.6 percent and 9.6 percent of the aggregate, respectively.^21,22 As this data shows, sepsis continues to be a prevalent and problematic condition with high costs. It is no surprise that it has warranted increased scrutiny by payers and thus, higher denial rates. It is important that facilities address the diagnosis, documentation, and coding of sepsis to ensure quality patient care and accurate reimbursement.

Scope and Objectives

The scope of this article is twofold: to provide a comprehensive review of the current challenges related to sepsis documentation, coding, and billing and to provide recommendations on how to address these challenges. A search was conducted of peer-reviewed articles published since 2017 related to the diagnosis and billing of sepsis using EBSCOhost database and Google Scholar.

The search was limited to this time period to highlight the challenges since the Sepsis-3 definitions were announced and had begun adoption amongst providers and payers. Search terms were used to identify sources that addressed sepsis definitions, coding sepsis, clinical documentation integrity (CDI) guidelines concerning sepsis, sepsis query recommendations, and sepsis-related claims denial management. Of the more than 200 articles reviewed, the content of nearly 100 specifically referenced the diagnostic and billing challenges of sepsis and associated recommendations. The research team recognizes that much of the expertise in this area is not evident in peer-reviewed journals. Thus, the search was expanded to professional journals and publications, as well as associated blogs and Q&A forums moderated by coding and CDI experts. This included the Journal of AHIMA, ICD-10 Monitor, Coding Clinic, Centers for Medicare & Medicaid Services (CMS) data tables, and Association of Clinical Documentation Integrity Specialists (ACDIS) publications and forums, among others. After screening the sources that met the criteria of the search, 95 sources were thoroughly evaluated for inclusion in this article. In total, 51 were used to synthesize the challenges of coding and billing for sepsis and recommendations to reduce sepsis-related claims denials.

The Challenges

Definitions and Clinical Indicators

According to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), sepsis is “life-threatening organ dysfunction caused by a dysregulated host response to infection.”²³ This organ dysfunction and dysregulated host response is what differentiates sepsis from other infections.²⁴ However, this definition still raises some confusion and controversy.²⁵ This may be due to the changing definitions of sepsis since 1992 when the Definitions for Sepsis and Organ Failure and Guidelines for the Use of Innovative Therapies in Sepsis first identified what is now referred to as Sepsis-1, based primarily around systemic inflammatory response syndrome (SIRS) with infection. This committee also introduced the concept of a continuum of severity, establishing a model of sepsis, severe sepsis, and septic shock. Septic shock is defined as “a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality.”²⁶ The definition was again revised in 2003, expanding the list of findings that may be seen in septic patients and defining sepsis “as the presence of infection and a wide list of general, inflammatory, perfusion, and hemodynamic parameters.”²⁷ These changing definitions shifted the diagnosis of sepsis from being based on SIRS with defined vital signs and laboratory values suggestive of infection to being based on organ dysfunction.²⁸

The Sepsis-3 definition relies on the measures of organ dysfunction, which can be based on a Sequential Organ Failure Assessment (SOFA) score of two points or more. The SOFA score is a mortality prediction score to grade the severity of organ dysfunction in the presence of infection. It is assumed a normal, healthy patient has a baseline SOFA score of zero.²⁹ This scoring model was developed and validated in an ICU setting; when used outside of the ICU it may underestimate organ dysfunction and sepsis.³⁰ Duke et al. found that “the SOFA score had high specificity but poor sensitivity for clinical sepsis,” stating that “clinical reliance on the SOFA score may delay recognition and treatment of patients during early stages of sepsis.”³¹ One challenge is that there are variable thresholds for defining organ dysfunction. As Rhee et al. states, “For example, there are multiple definitions for acute kidney injury, which differ from thresholds used in the SOFA score and other ICU-based organ dysfunction scores.”³²

Furthermore, this definition relies on some knowledge of baseline functioning that may not be known.³³ Patients may also be evaluated using the quick SOFA (qSOFA) score, but it has also been studied with mixed results. Arberry et al. found that qSOFA led to an overestimate of sepsis, recommending the use of both qSOFA and SOFA to clearly identify organ dysfunction.³⁴ In a study by Anand et al., of the 271,500 patients who had a positive qSOFA score on admission, only one in six had sepsis pointing to low sensitivity for identifying sepsis.³⁵ Salomao et al. found that the qSOFA lacked sensitivity when compared to the previous SIRS criteria and Evans et al., (2021) recommends “against using qSOFA compared with SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock.”^36,37 Singer et al. clarifies that “neither qSOFA nor SOFA is intended to be a stand-alone definition of sepsis.”³⁸ Similarly, SIRS is meant as a screening test.³⁹ The qSOFA should be used as the screening protocol within the first hour and then SOFA criteria becomes more credible with findings of organ dysfunction as the patient stay progresses.⁴⁰

In addition to the challenges related to defining and measuring organ dysfunction, the adoption of different sepsis definitions by various entities has added to the confusion. Some professional groups have declined to endorse the new Sepsis-3 standards, including The American College of Emergency Physicians, Infectious Diseases Society of America, and Latin American Sepsis Institute. CMS has shown preference for Sepsis-2 definitions for review and payment and Sepsis-1 measurement criteria over Sepsis-3.⁴¹ However, many other third-party payers have adopted Sepsis-3 criteria and recovery audit contractors (RACs) have begun moving towards Sepsis-3. In a member survey conducted by ACDIS (2020), 65 percent indicated that their facility uses Sepsis-2 criteria and only 15 percent use Sepsis-3 criteria. Physicians are not bound to a particular sepsis definition or set of criteria, and many hospitals are either still using Sepsis-2 criteria or unsure which one to use. This can lead to conflicting evaluations of claims and ultimately result in denials.⁴²

Regardless of the definition or clinical criteria, a sepsis diagnosis is dependent upon the patient story and physician judgment, and can be subjective.^43,44 Patients present with ailments that may or may not be infectious and organ dysfunction that may or may not be due to infection, and a septic patient may or may not have a positive blood culture and bacteremia may or may not cause sepsis.^45,46 The uncertainties in the diagnosis, scoring models, and clinical presentation can lead to unclear documentation that may negatively impact coding and ultimately lead to a denial. The physician’s documentation must make a clear connection between the abnormal clinical findings that support organ dysfunction and the diagnosis of sepsis.⁴⁷

Coding and CDI

Coding sepsis can often be as challenging as diagnosing it, with CMS guidelines keeping the “SIRS plus infection plus organ dysfunction” definition that does not clearly align with the new clinical definition of sepsis.⁴⁸ The AHA Coding Clinic Fourth Quarter 2017 states “a code is assigned when the provider documents sepsis and an associated acute organ dysfunction,” but this not always explicitly clear in physician documentation practice.⁴⁹ The listed conditions that are identified as representing acute organ dysfunction is not exhaustive and if the documentation is unclear it warrants a query.⁵⁰ When sepsis is coded, it is most commonly (72 percent of the time) code A41.9, Unspecific Sepsis.⁵¹

Additional challenges can arise when coding viral sepsis as ICD-10-CM does not provide a specific viral sepsis code, but rather directs A41.89, Other specified sepsis, as the best option.⁵² According to a random sample of 2021 fee-for-service claims through the Comprehensive Error Rate Testing (CERT) dataset, incorrect coding was indicated for 9.8 percent of MS-DRG 870 claims, 5.9 percent of MS-DRG 871 claims, and 8.5 percent of MS-DRG 872 claims.⁵³ Additional claim errors were noted for no documentation. This leads to an increased number of queries and possible underreporting. In a study done by Arberry et al., it was found that although 59 percent of the charts audited had evidence of sepsis at admission and 52 percent had sepsis documented somewhere in the notes, sepsis was much less likely to be documented on the discharge summaries (10 percent) or coded (17 percent).⁵⁴ Another study, by Wilhelms et al., concluded “that 55 percent of critically ill patients with severe sepsis were discharged from hospital without ICD codes that are widely used to identify sepsis.”⁵⁵ Similar studies have shown how poorly sepsis is coded in administrative data.⁵⁶

Sepsis raises challenges for CDI professionals as well. According to a 2019 survey by ACDIS, sepsis was the top queried diagnosis for clinical validation.⁵⁷ Clinical validation is a process by which documentation is evaluated to ensure that the medical record demonstrates enough clinical support for all documented diagnoses as mandated by the False Claims Act.⁵⁸ A clinical validation query request should be sent whenever there is a lack of clinical support for sepsis within the documentation. Options for specifying sepsis as “ruled in” or “ruled out” should be included in the query choices, in addition to the clinical indicators which support the diagnosis of sepsis during the current encounter.

Quality documentation ensures that anyone reading the medical record after discharge should come to the same conclusion as the providers in regards to the diagnosis of sepsis. Some speculate that the diagnosis of sepsis may be overused by the providers because the result of not treating a case of potential sepsis could be fatal for the patient. “Therefore, anyone who submits a clinical validation query for sepsis should consider the option of prophylactic or empiric treatment as a valid choice for those cases with little to no clinical support in the medical record.”⁵⁹ A note from the ACDIS editor in 2019 also indicated that sepsis remained a top search term for the organization’s website, highlighting the challenges and uncertainty that come with its documentation.⁶⁰

Denials and Payment Reviews

Despite these findings of potential underreporting, MS-DRGs 871 and 872 remain increasingly frequently billed DRGs leading to enhanced scrutiny by payers and challenges in compliance and reimbursement.⁶¹ These uncertainties make sepsis a regularly and controversially denied diagnosis.⁶² In a September 2022 Q&A forum, ACDIS indicated that nearly 70 percent of respondents to interviews of CDI professionals reported that sepsis was one of their top denied diagnoses.⁶³ Most denials are due to a lack of documentation or clear clinical indicators; even when coded based on a definite physician diagnosis, missing clinical indicators can lead to a denial.^64,65 This may be due, in part, to payers capitalizing on the gaps between Sepsis-2 and Sepsis-3 clinical criteria.⁶⁶

It is important that those involved in the revenue cycle check insurance contracts for clear definitions and requirements. The record may not show evidence of impaired homeostasis as evidenced by altered mental status from baseline, hyperglycemia, hypotension, oliguria, coagulopathy, thrombocytopenia, ileus, acute hepatic failure, elevated lactate and capillary mottling, or acute respiratory distress syndrome, among others.⁶⁷ The payer may indicate “there is no evidence that the patient’s symptoms were due to any localized infection” or may acknowledge the condition as documented, but not “think this was a valid diagnosis.”⁶⁸ The record may lack laboratory findings that support SOFA indicators or clinical evidence of SOFA criteria. Denials have included reasonings such as “no mention of toxic in appearance” or “no positive blood culture.” The treatment plan is also considered and may result in a denial if it does not reflect the greater levels of monitoring and intervention required to treat sepsis.⁶⁹ Continued issues in the documentation and coding of sepsis will only lead to increased denials and audits.⁷⁰

Recommendations

In order to accurately diagnosis and bill for sepsis, facilities must identify their sepsis issues and their impact on the facility. This includes identifying the prevalence of sepsis and sepsis-related issues (such as denials) in their patient population by considering community demographics, their payer mix, claims and quality reporting data, and benchmarks. Costs can be identified through various reports and payer contracts, and current medical definitions should be clarified. Once the problem has been clarified, there are strategies to improve sepsis diagnosis, documentation, coding, and billing. A consistent, system-wide approach should be used utilizing a sepsis team that may include medicine and nursing, laboratory and pharmacy, billing and admitting, coding, CDI, and quality assurance.⁷¹

Policies and Tools

Facilities need to clarify which sepsis definitions and criteria are being used to ensure consistency between providers.⁷² Even if it is decided to use different criteria than the payer, having clear definitions and documentation guidelines can support an argument for denial by highlighting standardized internal criteria.^73,74 Institutional definitions provide consistency and clarity for providers, coders, and CDI staff in documentation, education, clinical validation, and the query process.⁷⁵ Including a works cited with facility definitions helps verify that the criteria is from the industry, not just an individual facility.⁷⁶

A consensus statement should define sepsis and severe sepsis, and provide guidance regarding documentation of “early sepsis” or “meets sepsis criteria.”⁷⁷ Facilities should review and update sepsis screening policies, intake forms, and treatment protocols utilizing a multidisciplinary group of medical professionals to ensure they meet the designated definitions.⁷⁸ Working together to clarify and update the definitions, policies, and tools encourages conversation across multiple departments and helps the facility establish common standards and consistency.⁷⁹

Diagnostic criteria should be established for the organization and communicated to clinical staff for accurate recognition and reporting of sepsis based on infection and organ dysfunction.⁸⁰ Facility-defined clinical indicators including sepsis screening criteria, definitions, and SOFA criteria should be clearly communicated and readily available to clinical staff .⁸¹ This could be incorporated into a template, such as a discharge summary template, to provide clinicians with an aide and encourage thorough documentation. This can then be used by the coders as a clear indication of sepsis.⁸² Arberry et al. found that implementing such a template improved sepsis documentation by 28 percent.⁸³ Organizations such as ACDIS provide forms and tools such as query templates. Some electronic health record vendors, such as Epic, provide dropdown menus that guide more specific documentation and/or scoring tools such as a SOFA score calculator.⁸⁴ Facilities may also consider creating a care process model like the one created by a workgroup at Intermountain Healthcare that provides algorithms for diagnosing and treating sepsis and septic shocks, outlines important definitions and clinical characteristics, and includes an adult sepsis bundle worksheet and tidal volume conversion tables.⁸⁵ Such algorithms can clearly show the clinical indicators that led to the diagnosis of sepsis. Once facility-wide definitions and criteria are decided upon, a process should be put in place to regularly re-assess and update the criteria to ensure compliance with the latest clinical guidance and coding guidelines.⁸⁶

Policies and procedures related to the coding and billing of sepsis should also be reviewed. It should be clear when coding and CDI queries are needed to establish sepsis. Coding and CDI staff should work together to ensure clinical indicators clearly support a diagnosis of sepsis, and query when the evidence is insufficient.⁸⁷ For example, the ICD-10-CM official guidelines recommend querying about a negative or inconclusive blood culture, documentation of “urosepsis,” and any indication of acute organ dysfunction if it is not clear that it is related to sepsis. Competing etiologies can weaken the validity of sepsis and should be outlined in a query to ensure the provider has all key pieces of information.⁸⁸ Query templates may be helpful to ensure they include the relevant clinical indicators to support the diagnosis of sepsis.⁸⁹ Organizations may want to implement pre-bill reviews for sepsis stays.⁹⁰ The facility should establish clear escalation policies and the need for a second-level review for sepsis claims and denials. Rebutting a denial should be supported by a comprehensive appeal letter. A standard appeal template may be helpful, particularly for repeated denials related to a disagreement between sepsis definitions and clinical criteria.⁹¹

Payer contracts should specify which definition of sepsis and diagnostic criteria the payer is using. As changes are made to payment policies and contracts with payers, these changes need to be communicated to providers and revenue cycle staff. Such contracts should outline the desired clinical information, facts, and context needed to support a diagnosis of sepsis.⁹² For example, if an organization decides to use the SIRS criteria, this should be reflected in the contract so if denials arise due to a conflict between the SIRS criteria and Sepsis-3 criteria, the facility to can refer back to the contract in their appeal letter.⁹³ Compare payer denial activity to contract terms and identify issues. If sepsis claims are continuing to be denied even when agreed upon criteria are being used, there could be an error occurring such as a disconnect with a third-party reviewer. Track contact requirements to ensure they are being met and follow up as needed.⁹⁴

Education and Training

Clinical staff may need updated training on documentation requirements. They should be encouraged to document a clear clinical picture including signs and symptoms to indicate both the infection and organ dysfunction, tying together observations, indicators, and logic.^95,96 An infection without organ failure may sometimes be described as “septic”, but does not actually meet the definition of “sepsis.”⁹⁷ Documentation needs to identify “sepsis,” “severe sepsis,” or “septic shock,” be clear and consistent, identify the source of infection, and clarify that the sepsis is related to the source infection. Clarifying the relationships can be evident with words like “causing” or “caused by,” “associated with” or “related to,” “from,” “due to,” or “with.”⁹⁸

The documentation must include a statement like “dysregulated host response to infection” and the association organ dysfunction, such as hypotension, renal failure, encephalopathy, etc.⁹⁹ General phrases such as “multiple system organ failure” should be avoided.¹⁰⁰ Clarifying a clear relationship is important. Rather than stating “elevated creatinine in the setting of sepsis, hypotension,” a statement such as “acute kidney injury, likely due to sepsis with hypotension” shows a stronger link between the conditions. Documentation should also clarify if the infection was or may have been related to a recent surgery or device and if it was present on admission.¹⁰¹

Regardless if the sepsis resolves during an inpatient stay, discharge summary documentation should highlight that sepsis was a condition on admission through consistent documentation by all providers.^102,103 If using the Sepsis-3 definition, clinical staff should be encouraged to include the SOFA and/or qSOFA score on every chart where sepsis is a diagnostic consideration.

In addition to clarifying what providers need to include in sepsis documentation, training may also need to be provided on what to avoid or use caution with when documenting. Providers should avoid sepsis-adjacent phrases, such as “urosepsis,” “sepsis-like,” “meets sepsis criteria,” or “sepsis syndrome.”¹⁰⁴ The term “urosepsis” is vague and nonspecific; if the patient has sepsis due to a urinary tract infection, that must be clarified in the documentation.¹⁰⁵ Even terms such as “septicemia,” “SIRS,” and “septic, toxic” can be problematic because they may describe infection but do not definitively clarify sepsis with organ dysfunction. Documenting a “history of sepsis” does not indicate the condition on the current stay, even if it resolved following admission.¹⁰⁶ Although R78.81 Bacteremia will still group to MS-DRGS 870-872, documenting “bacteremia” alone can also be problematic. Providers may use these terms interchangeably, but by the coding definition bacteremia does not usually meet medical necessity for an inpatient admission as it implies the patient is asymptomatic.¹⁰⁷ If sepsis is present, documentation should indicate it with statements like “sepsis due to e-colic bacteremia” or “sepsis with positive blood cultures.”^108,109

In addition to education and training for clinical staff, a targeted effort should be made to ensure all coding and CDI staff are adequately trained on the new definitions and clinical criteria. Documentation of SIRS with an infection is no longer enough to code sepsis; coders needs to look for sepsis and organ dysfunction.¹¹⁰ Arberry et al. found that additional training for coders improved their ability to capture a sepsis code by 21 percent.¹¹¹ CDI staff need to look for the progression of infectious symptoms throughout the patient stay and for contradictory notes between the emergency department and attending physician.¹¹² Does the treatment provided support the diagnosis of sepsis? According to DeFilippis, “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.”¹¹³ Using the facility-wide definitions and clinical criteria as decided on to frame queries shows cohesion across the organization and may help with future appeals.¹¹⁴

Examples of circumstances that may indicate a need for CDI assessment and a possible query include, but are not limited to:

Less defined diagnostic language, such as “septicemia” or “urosepsis”
Unspecified type of sepsis
Conflicting diagnoses throughout the chart
Lack of language clarifying the relationship between the source infection and sepsis
Lack of language clarifying the relationship between organ damage and severe sepsis or septic shock
Lack of identified source infection
Lack of positive blood cultures
Lack of SIRS/SOFA indicators
Documentation of sepsis in only one chart document
An indication that the sepsis protocol/bundle was provided without documented sepsis
Lack of clinical indicators¹¹⁵

The CDI team can help to escalate documentation issues and engage the physician champion to work with physicians who struggle with providing the appropriate criteria.¹¹⁶ It is important that providers know the CDI and coding staff are on their side and that accurate documentation and code assignment are vital to quality patient care.¹¹⁷

With so many involved in the revenue cycle, it is important to encourage and support collaboration between contract teams, physicians, coders, CDI professionals, and quality assurance professionals. When concerns are communicated to the contracting team, the payer representative can work to address them with the payer.¹¹⁸ Training should then be provided to clarify any updated changes in the contract. CDI professionals should take time to review any potential sepsis records holistically to address any insufficiencies with the provider, using it as an opportunity to educate rather than simply query. Taking time to improve documentation at the source will create a sustainable change in capturing accurate sepsis diagnosis.¹¹⁹ CDI should also work with quality assurance to ensure consistent and high-quality claims data that supports quality indicators.¹²⁰

Denial Management

Despite best efforts, denials will still occur. The majority of denials come from multiple sets of criteria for the diagnosis of sepsis, physician documentation, and change in definition of sepsis. “The majority of sepsis denials are clinical denials. Clinical denial audits are where the payer is questioning whether or not the physician’s diagnosis of sepsis is clinically supported.”¹²¹

Facilities should address denials by reviewing the medical record to identify significant findings the auditor may have missed, being prepared to defend the claim. Those working on denials must rely on official coding guidelines and medical literature and should support physicians when fighting a challenging denial.¹²² They should collaborate with coders, CDI staff, and physicians to ensure that the documentation clearly describes the condition of sepsis. In addition, denial management should never depend on the denial letters to list all the clinical indicators; rather, they should always review the record to be sure that there are no other clinical findings to help support the diagnosis that was reported. Appeal letters should acknowledge the differences of opinion and must include all supporting documentation and references that help support the diagnosis of sepsis.¹²³

This literature review was predominantly limited to the primary publications from organizations that represent health information management and clinical documentation integrity. The study may not have captured all relevant articles based on search terms and databases used. Future studies should focus on empirical research methods to analyze sepsis-related documentation, coding practices, and claims data. Furthermore, the recommendations in this literature review are based on the practices of a variety of professionals. Facilities are encouraged to internally monitor improvements based on any changes made to continue to make modifications and verify which improvements are impacting sepsis-related patient outcomes and denial rates.

Conclusion

Sepsis will continue to be one of the most frequent and expensive conditions billed for making it ever more important to be diagnosed, billed and reimbursed accurately.

However, until there is a consensus on sepsis definitions, an adoption of new clinical criteria, or new set of sepsis codes, challenges and discrepancies will remain. Differing definitions and interpretations of clinical indicators leads to inconsistencies in documentation, impacting coding and ultimately the claim. The increasing number and steadily progressing costs of treating the condition have payers scrutinizing sepsis-related claims.

Facilities need to clarify institutional definitions to ensure consistency throughout the organization and alignment with what is outlined in payer contracts. Clinicians may need updated training and education on sepsis definitions and clinical indicators, and how to document them in a way that accurately reflects the patient condition. Facilities may also consider updating systems, templates, and algorithms to guide clinicians in quality documentation. Coding and CDI staff should also be involved in these training efforts to ensure alignment between documentation and coding.

Ultimately, having a clearly defined model within a facility can prevent denials and help support appeals. Most importantly, although much of the literature reviewed focused on accurate coding and billing of sepsis, the accurate diagnosis and treatment of sepsis is essential to improving the care and outcomes of patients (Remer, 2019).¹²⁴

Tables and Figures

Table 1: 2020 Medicare Inpatient Hospitals – National Figures with Range by State¹²⁵
MS-DRG	Discharges		Average Submitted Charge		Average Medicare Payment Amount
MS-DRG 870^*	National	42,625	National	$249,413.56	National	$49,689.83
	California	5,187	Nevada	$458,644.99	Alaska	$70,513.65
	Vermont	16	Maryland	$84,231.85	Arkansas	$35,897.21
MS-DRG 871^**	National	587,611	National	$69,793.85	National	$13,357.43
	California	65,337	Nevada	$128,860.04	Maryland	$20,876.51
	Wyoming	612	Maryland	$24,468.77	Vermont	$10,077.82
MS-DRG 872^***	National	128,651	National	$38,568.70	National	$6,931.09
	California	14,105	New Jersey	$64,627.85	Alaska	$10,585.30
	Wyoming	194	Maryland	$12,965.16	Vermont	$5,186.86
MS-DRG 870 Septicemia or Severe Sepsis with MV >96 hours MS-DRG 871 Septicemia or Severe Sepsis w/o MV >96 hours w/ MCC **MS-DRG 872 Septicemia or Severe Sepsis w/o MV >96 hours w/o MCC

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Engoren, Milo, Troy Seelhammer, Robert E. Freundlich, Michael D. Maile, Matthew JG Sigakis, and Thomas A. Schwann. "A Comparison of Sepsis-2 (Systemic Inflammatory Response Syndrome Based) to Sepsis-3 (Sequential Organ Failure Assessment Based) Definitions–A Multicenter Retrospective Study." Critical Care Medicine 48, no. 9 (2020): 1258.

Evans, Laura, Andrew Rhodes, Waleed Alhazzani, Massimo Antonelli, Craig M. Coopersmith, Craig French, Flávia R. Machado et al. "Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021." Intensive Care Medicine 47, no. 11 (2021): 1181-1247.

Fingar, Kathryn R., Marguerite L. Barrett, and H. Joanna Jiang. “A comparison of all-cause 7-day and 30-day readmissions, 2014: Statistical Brief #230.” Agency for Healthcare Research and Quality (2017).

Fleischmann-Struzek, Carolin, Daniel O. Thomas-Rüddel, Anna Schettler, Daniel Schwarzkopf, Angelika Stacke, Christopher W. Seymour, Christoph Haas, Ulf Dennler, and Konrad Reinhart. "Comparing the validity of different ICD coding abstraction strategies for sepsis case identification in German claims data." PloS one 13, no. 7 (2018): e0198847.

Frady, Allen. “Note from the instructor: Sepsis – stop looking at it as just one set of criteria.” CDI Strategies 12, no. 21 (2018).

Frady, Allen. “Q&A: Conflicting documentation of sepsis and bacteremia.” CDI Blog 11, no. 171 (2018).

Hasaballa, Hesham. “Avoiding sepsis denials.” Sound Physicians (November 29, 2017). https://soundphysicians.com/blog/avoiding-sepsis-denials/

Health Care Compliance Association (HCCA). “Payer denials hit sepsis amid conflicting clinical protocols; diagnosis is doubted.” Report on Medicare Compliance 26, no. 18 (2017).

Intermountain Healthcare. “Recognition and Management of severe sepsis and septic shock.” Care Process Model (August 2020).

Jiang, H. Joanna, Audrey J. Weiss, Marguerite L. Barrett, and Minya Sheng. “Characteristics of hospital stays for super-utilizers by payer, 2012: Statistical Brief #190.” Agency for Healthcare Research and Quality (2015).

Klompas, Michael, and Chanu Rhee. "Current sepsis mandates are overly prescriptive, and some aspects may be harmful." Critical Care Medicine 48, no. 6 (2020): 890-893.

Krauss, Glenn. “Tread lightly with sepsis MS-DRGs.” ICD10monitor (May 11, 2021). https://icd10monitor.medlearn.com/tread-lightly-with-sepsis-ms-drgs/

Kuqi, Alba. “Successfully appealing clinical validation and coding issues in sepsis.” Journal of AHIMA (October 26, 2021).

Liang, Lan, Brian Moore, and Anita Soni. “National inpatient hospital costs: The most expensive conditions by payer, 2017: Statistical Brief #261.” Agency for Healthcare Research and Quality (2020).

Maigur, Andrew. “Surviving the Sepsis-3 condundrum.” Premier Pulse (September 26, 2019). https://www.premierhealth.com/your-health/articles/premier-pulse/surviving-the-sepsis-3-conundrum

McBrayer, Shelly, and Cesar M. Limjoco. “Q&A: Facility-specific sepsis criteria.” CDI Blog 11, no. 200 (2018).

McDermott, Kimberly W., Anne Elixhauser, and Ruirui Sun. “Trends in hospital inpatient stays in the United States, 2005-2014: Statistical Brief #225.” Agency for Healthcare Research and Quality (2017).

McDermott, Kimberly W., and Marc Roemer. “Most frequent principal diagnoses for inpatient stays in U.S. hospitals, 2018: Statistical Brief #227.” Agency for Healthcare Research and Quality (2021).

National Association of Healthcare Revenue Integrity (NAHRI). “Refreshing denial management: Targeting trends with data and collaboration.” NAHRI Journal 6, no. 1 (2022).

Nehring, Sarah. “Coding corner: 10 things every coder wishes providers knew about sepsis documentation and coding.” CDI Journal 13, no. 3 (2019).

Parker, Shirlivia M. “How CDI professionals can lead the clinical validation denials process.” Journal of AHIMA (March 14, 2022).

Penn State Health Milton S. Hershey Medical Center. “Facility defined clinical indicators for adult sepsis.”

Remer, Erica E. “Payers and clinicians should use clinically accepted criteria when diagnosis sepsis.” ICD10monitor (January 28, 2019). https://icd10monitor.medlearn.com/payers-and-clinicians-should-use-clinically-accepted-criteria-when-diagnosing-sepsis/

Rhee, Chanu, Maximilian S. Jentzsch, Sameer S. Kadri, Christopher W. Seymour, Derek C. Angus, David J. Murphy, Greg S. Martin et al. "Variation in identifying sepsis and organ dysfunction using administrative versus electronic clinical data and impact on hospital outcome comparisons." Critical Care Medicine 47, no. 4 (2019): 493.

Riel, Carolyn. “Fight until the very end: Sepsis and malnutrition denials.” CDI Journal 14, no. 6 (2020).

Rodenberg, Howard, and the ACDIS Regulatory Committee. “Sepsis’ clinical evolution: Understand essential challenges to developing effective queries.” Association of Clinical Documentation Improvement Specialists (2019).

Salomão, R., B. L. Ferreira, M. C. Salomão, S. S. Santos, L. C. P. Azevedo, and M. K. C. Brunialti. "Sepsis: evolving concepts and challenges." Brazilian Journal of Medical and Biological Research 52 (2019).

Singer, Mervyn, Clifford S. Deutschman, Christopher Warren Seymour, Manu Shankar-Hari, Djillali Annane, Michael Bauer, Rinaldo Bellomo et al. "The third international consensus definitions for sepsis and septic shock (Sepsis-3)." Jama 315, no. 8 (2016): 801-810.

Tian, Wen. “An all-payer view of hospital discharge to postacute care, 2013: Statistical Brief #205.” Agency for Healthcare Research and Quality (2016).

Torio, Celeste M., and Roxanne M. Andrews. “National inpatient hospital costs: The most expensive conditions by payer, 2011: Statistical Brief #160.” Agency for Healthcare Research and Quality (2013).

Torio, Celeste M., and Brian J. Moore. “National inpatient hospital costs: The most expensive conditions by payer, 2013: Statistical Brief #204.” Agency for Healthcare Research and Quality (2016).

Valdez, Dawn. “Note from the instructor: Sepsis clinical indicators, competing etiologies – a critical thinking exercise.” CDI Blog 14, no. 29 (2021).

Valdez, Dawn. “Q&A: Clinical validation of sepsis and clinical criteria.” CDI Strategies 16, no. 50 (2022).

Weiss, Audrey J., and H. Joanna Jiang. “Overview of clinical conditions with frequent and costly hospital readmissions by payer, 2018: Statistical Brief #278.” Agency for Healthcare Research and Quality (2021).

Wilhelms, S. B., S. M. Walther, Fredrik Huss, and Folke Sjöberg. "Severe sepsis in the ICU is often missing in hospital discharge codes." Acta Anaesthesiologica Scandinavica 61, no. 2 (2017): 186-193.

Arberry, Jamie, et al. "A simple measure to improve sepsis documentation and coding." Clinical Medicine 21, no. 3 (2021): 222.
Duke, Graeme J., et al. "Performance of hospital administrative data for detection of sepsis in Australia: The sepsis coding and documentation (SECOND) study." Health Information Management Journal (2022).
Singer, Mervyn, et al. "The third international consensus definitions for sepsis and septic shock (Sepsis-3)." Jama 315, no. 8 (2016): 801-810.
Krauss, Glenn. “Tread lightly with sepsis MS-DRGs.” ICD10monitor (May 11, 2021).
Arberry et al.
McDermott, Kimberly W., and Marc Roemer. “Most frequent principal diagnoses for inpatient stays in U.S. hospitals, 2018: Statistical Brief #227.” Agency for Healthcare Research and Quality (2021).
Torio, Celeste M., and Roxanne M. Andrews. “National inpatient hospital costs: The most expensive conditions by payer, 2011: Statistical Brief #160.” Agency for Healthcare Research and Quality (2013).
McDermott et al. (2021).
Liang, Lan, et al. “National inpatient hospital costs: The most expensive conditions by payer, 2017: Statistical Brief #261.” Agency for Healthcare Research and Quality (2020).
Torio et al. (2013).
Torio, Celeste M., and Brian J. Moore. “National inpatient hospital costs: The most expensive conditions by payer, 2013: Statistical Brief #204.” Agency for Healthcare Research and Quality (2016).
McDermott et al. (2021).
Barrett, Marguerite L., et al. “Utilization of intensive care services, 2011: Statistical Brief #185.” Agency for Healthcare Research and Quality (2014).
Jiang, H. Joanna, et al. “Characteristics of hospital stays for super-utilizers by payer, 2012: Statistical Brief #190.” Agency for Healthcare Research and Quality (2015).
Tian, Wen. “An all-payer view of hospital discharge to postacute care, 2013: Statistical Brief #205.” Agency for Healthcare Research and Quality (2016).
Fingar, Kathryn R., et al. “A comparison of all-cause 7-day and 30-day readmissions, 2014: Statistical Brief #230.” Agency for Healthcare Research and Quality (2017).
Weiss, Audrey J., and H. Joanna Jiang. “Overview of clinical conditions with frequent and costly hospital readmissions by payer, 2018: Statistical Brief #278.” Agency for Healthcare Research and Quality (2021).
McDermott et al. (2021).
McDermott, Kimberly W., et al. “Trends in hospital inpatient stays in the United States, 2005-2014: Statistical Brief #225.” Agency for Healthcare Research and Quality (2017).
Fingar et al.
Ibid.
Weiss and Jiang.
Singer et al., 805.
Ibid.
Duke et al.
Singer et al., 805.
Rodenberg, Howard, and the ACDIS Regulatory Committee. “Sepsis’ clinical evolution: Understand essential challenges to developing effective queries.” Association of Clinical Documentation Improvement Specialists (2019): 2.
Engoren, Milo, et al. "A Comparison of Sepsis-2 (Systemic Inflammatory Response Syndrome Based) to Sepsis-3 (Sequential Organ Failure Assessment Based) Definitions–A Multicenter Retrospective Study." Critical Care Medicine 48, no. 9 (2020): 1258.
Singer et al.
Duke et al.
Ibid.
Rhee, Chanu, et al. "Variation in identifying sepsis and organ dysfunction using administrative versus electronic clinical data and impact on hospital outcome comparisons." Critical Care Medicine 47, no. 4 (2019): 497.
Frady, Allen. “Note from the instructor: Sepsis – stop looking at it as just one set of criteria.” CDI Strategies 12, no. 21 (2018).
Arberry et al.
Anand, Vijay, et al. "Epidemiology of quick sequential organ failure assessment criteria in undifferentiated patients and association with suspected infection and sepsis." Chest 156, no. 2 (2019): 289-297.
Salomão, R., et al. "Sepsis: evolving concepts and challenges." Brazilian Journal of Medical and Biological Research 52 (2019).
Evans, Laura, et al. "Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021." Intensive Care Medicine 47, no. 11 (2021): 1064.
Singer et al., 807.
Frady.
McBrayer, Shelly, and Cesar M. Limjoco. “Q&A: Facility-specific sepsis criteria.” CDI Blog 11, no. 200 (2018).
Rodenberg and the ACDIS Regulatory Committee.
Riel, Carolyn. “Fight until the very end: Sepsis and malnutrition denials.” CDI Journal 14, no. 6 (2020).
Klompas, Michael, and Chanu Rhee. "Current sepsis mandates are overly prescriptive, and some aspects may be harmful." Critical Care Medicine 48, no. 6 (2020): 890-893.
Krauss.
Arberry et al.
Klompas and Rhee.
Kuqi, Alba. “Successfully appealing clinical validation and coding issues in sepsis.” Journal of AHIMA (October 26, 2021).
Hasaballa, Hesham. “Avoiding sepsis denials.” Sound Physicians (November 29, 2017).
American Hospital Association (AHA). “Severe sepsis and acute organ dysfunction/failure.” Coding Clinic, Fourth Quarter (2017).
Ibid.
DeFilippis, Margaret. “Achieving and protecting sepsis reimbursement.” Managed Resources (May 30, 2019).
AHA. “Sepsis coding issues.” Coding Clinic, Third Quarter (2016).
CMS. “Medicare fee-for-service comprehensive error rate testing.” Data.CMS.gov (2021).
Arberry et al.
Wilhelms, S. B. et al. "Severe sepsis in the ICU is often missing in hospital discharge codes." Acta Anaesthesiologica Scandinavica 61, no. 2 (2017): 189.
Arberry et al.
Archibald, Linnea. “Note from the ACDIS editor: Resources for everyone’s favorite topic.” CDI Strategies 13, no. 46 (2019).
Valdez, Dawn. “Q&A: Clinical validation of sepsis and clinical criteria.” CDI Strategies 16, no. 50 (2022).
Ibid.
Archibald.
Krauss.
Parker, Shirlivia M. “How CDI professionals can lead the clinical validation denials process.” Journal of AHIMA (March 14, 2022).
ACDIS. “2022 CDI week bonus Q&A: Denial trends and CDI involvement.” CDI Strategies 16, no. 40 (2022).
Boy, Kim. “Reasons for denials and prevention: Sepsis series.” Health Information Associates (November 22, 2019).
DeFilippis.
HCCA. “Payer denials hit sepsis amid conflicting clinical protocols; diagnosis is doubted.” Report on Medicare Compliance 26, no. 18 (2017).
Boy.
DeFilippis, 38.
Boy.
Krauss.
DeFilippis.
Riel, Carolyn. “Fight until the very end: Sepsis and malnutrition denials.” CDI Journal 14, no. 6 (2020).
Frady.
McBrayer and Limjoco.
Rodenberg and the ACDIS Regulatory Committee.
ACDIS. “Setting guideposts: Organizationwide clinical definitions.” CDI Journal 13, no. 5 (2019).
ACDIS. “Q&A: Clinical validation of sepsis.” CDI Blog 11, no. 3 (2018).
Riel.
ACDIS (2019).
Arberry et al.
Penn State Health Milton S. Hershey Medical Center. “Facility defined clinical indicators for adult sepsis.”
Arberry et al.
Ibid.
Maigur, Andrew. “Surviving the Sepsis-3 condundrum.” Premier Pulse (September 26, 2019).
Intermountain Healthcare. “Recognition and Management of severe sepsis and septic shock.” Care Process Model (August 2020).
ACDIS (2019).
HCCA.
Valdez, Dawn. “Note from the instructor: Sepsis clinical indicators, competing etiologies – a critical thinking exercise.” CDI Blog 14, no. 29 (2021).
Riel.
HCCA.
ACDIS. “Q&A: Sepsis appeals.” CDI Strategies 15, no. 18 (2021).
Krauss.
Riel.
National Association of Healthcare Revenue Integrity (NAHRI). “Refreshing denial management: Targeting trends with data and collaboration.” NAHRI Journal 6, no. 1 (2022).
HCCA.
Krauss.
Hasaballa.
DeFilippis.
Hasaballa.
Maigur.
Nehring, Sarah. “Coding corner: 10 things every coder wishes providers knew about sepsis documentation and coding.” CDI Journal 13, no. 3 (2019).
Maigur.
Nehring.
Maigur.
Nehring.
DeFilippis.
Frady.
Ibid.
Nehring.
Ibid.
Arberry et al.
Riel.
DeFilippis, 33.
ACDIS (2019).
DeFilippis.
Riel.
Nehring.
Parker, Shirlivia M. “How CDI professionals can lead the clinical validation denials process.” Journal of AHIMA (March 14, 2022).
Krauss.
DeFilippis.
Boy.
Riel.
Boy.
Remer, Erica E. “Payers and clinicians should use clinically accepted criteria when diagnosing sepsis.” ICD10monitor (January 28, 2019).
CMS. “Medicare inpatient hospitals – by geography and service.” Data.CMS.gov (2020).

Author Biographies

Alba Kuqi MD, MSHIM ,RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , is a candidate pursuing a Doctor of Public Health degree at Georgia Southern University in Statesboro, Georgia, with a passion for advancing public health initiatives and making a meaningful impact on communities.

Jaime Sand, EdD, RHIA, CCS, CAHIMS, is a professor and associate director of student engagement and Impact at Boise State University in the School of Public and Population Health.