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Sigh. Sepsis…

Denials are rampant.
Hospitals are losing money.
Patients are stuck in a coding no man’s land.
But as time goes on, the problem and its fix is becoming fairly obvious.

It comes down to this: our current coding system (and their clinical definitions) forces an either-or choice between “localized infection” and “sepsis with life-threatening organ dysfunction.” But there is no way to capture the very real middle ground.

That missing middle is creating a clinical headache, and a financial one.

Almost a Decade Since Sepsis-3

It has been nearly ten years since the publication of Sepsis-3 in February 2016.

For those who need a refresher, Sepsis-3 defined sepsis as:

This was a big shift from the long-standing definition based on “Systemic Inflammatory Response Syndrome” (SIRS) criteria, used in some form since 1991 (and updated in 2001 as Sepsis-2). I’ve written a previous newsletter on this topic here.

The Debate Is Far From Over

Despite many declaring the issue settled, the “sepsis debate” is alive and well.

CMS still uses Sepsis-2 and has doubled down on it. And there is certainly not universal adoption of Sepsis-3. Many bedside physicians still use Sepsis-2 and have not rushed to adopt Sepsis-3, even when educated on it. I contrast this to the 4th universal definition of myocardial infarction. Even if physicians have never heard of it, after being educated most adopt it quickly because it makes clinical sense.

Sepsis-3 has legitimate problems, and ignoring them means ignoring questions about the impacts on patients and the very real effect on hospital reimbursement.

The American Hospital Association said it well in a letter to CMS last year:

Yes, Sepsis-3 predicts mortality better than Sepsis-2. That’s great for research, but not so great for early identification - a key to sepsis treatment and survival. The Surviving Sepsis campaign has adopted the Sepsis-3 definition, but not the qSOFA screening tool (preferring SIRS as a screening tool).

But don’t confuse my lack of loving Sepsis-3 clinically with an endorsement of Sepsis-2. I see Sepsis-2 used improperly frequently and it’s a major problem. Sepsis-2 is certainly not the answer, either.

But This Newsletter Is Not About That Debate

That is the last I will say about Sepsis-2 versus Sepsis-3. This is not about winning that argument. Sepsis-3 is not going back into the toothpaste tube and with being almost a decade in, I doubt a new clinical definition will be developed to solve this issue.

So, we need a different fix - one that addresses both clinical concerns and reimbursement realities.

(But for the rest of this issue, when I say “sepsis,” I am implying by Sepsis-3 definition)

The Missing Middle

Right now, coding forces an either-or choice:

• Localized infection

• Sepsis with life-threatening end-organ dysfunction

Does that sound right to you?
Do patients go from having pneumonia to suddenly BAM! full-blown sepsis with life-threatening organ dysfunction?
Of course not.
There’s a progression.
A spectrum.

And can we prevent that progression? Absolutely. It’s the whole point in early recognition and treatment.

And do all patients with localized infection require the aggressive resources to prevent that progression? No.

This spectrum used to be captured by:

• The localized infection code

• The Sepsis code

• The additional code for Severe Sepsis

• The additional code for Septic Shock

Now, “severe sepsis” is redundant and unnecessary, so we’ve lost the middle ground of that spectrum.

How This Hurts Hospitals

While the lack of clinical consensus should be, and is, a major influencer of proposing a potential fix, the reality is that the hospital reimbursement issue is forcing this issue to the top.

CMS calculates DRG reimbursement by tracking and averaging the cost of treating each condition. Because CMS still uses Sepsis-2, their dataset includes patients without organ dysfunction. Those cases use fewer resources, which drives the average cost (and thus payment) for sepsis DRGs down (In RCM lingo, this is “artificially lowering the relative weight of sepsis DRGs”).

This means that hospitals treating true Sepsis-3 patients are under reimbursed. If you’re keeping track, that means it’s a doubly wammy when payers layer on extra criteria like “after hydration” or “after ED treatment” before they will accept a Sepsis-3 diagnosis (i.e. issuing clinical validation denials).

The Proposed Fix: A New Code

A group of industry leaders, including Dr. James Kennedy, Dr. Cesar Limjoco, Dr. R. Kendall Smith, Penny Jefferson, and Shirlivia Parker, have proposed creating a new ICD-10-CM code for “early sepsis” or “pre-sepsis.”

I support this initiative.

These terms are intuitive to physicians. When explaining this issue to other physicians (the lack of a code that captures this spectrum) they will often interject and say “like early sepsis?” before I even mention it. So, I suspect this new term will be easily adopted by physicians.

Additionally:

• CMS could use the code to track it for appropriate reimbursement (possibly as a comorbid condition (CC/MCC), rather than mapping to a sepsis DRG).

• Over time, these pre-Sepsis patients would be removed from Sepsis DRG calculations, driving reimbursement for true Sepsis-3 cases upward appropriately.

If Sepsis is simply too loaded of a term and results in push back, we could alternatively consider something like “Infection with systemic signs or symptoms.” A code for “SIRS” could make sense here, as there are codes for “SIRS due to non-infectious origin.” However, I would prefer to avoid the term “SIRS” to future-proof the code against evolving criteria changes (and prevent us from having to do a coding change debate all over again).

But, I’ll leave that debate to the decision-makers. I just want to raise awareness and start a conversation about the issue and this potential fix.

But What About a Clinical Definition?

Yes, there is no clear universal definition for this pre-sepsis condition. But not every ICD-10-CM code has one.

What is the universally accepted definition of chronic hepatic failure? Chronic cerebral ischemia? Acute respiratory failure with hypoxia? None exist, yet the codes do, and they have major impacts on quality reporting and reimbursement.

In fact, the code creation could lead to the development of an accepted definition as it would allow tracking of this pre-sepsis state.

Moving This Forward

To make this happen, we need help from, among others,:

• The American Hospital Association

• The Sepsis Alliance

• The Surviving Sepsis Campaign

• AHIMA

• ACDIS

• CDC NCHS

• CMS

Certainly endorsement from clinical professional organizations such as the IDSA would also be helpful.

If you believe in this cause and know someone in these organizations, please share this newsletter with them. Even if they disagree with this proposed fix, we need to start a conversation.

But in my view, this solution makes a lot of sense, both clinical and financial.

Share your thoughts in the comments, or on Linkedin!

That’s all for now. Cheers,

Robert

Thanks to Dr. James Kennedy for his input, and thank you to Laura Samson, RN BSN CCDS for editing this newsletter!

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