Let’s explore the common causes behind sepsis record denials and how coders can assist in addressing these issues.

Why do sepsis records face frequent denials? Pinpointing the exact cause for the recent surge in sepsis denials is challenging. However, it’s likely due to the diverse diagnostic criteria for sepsis, evolving definitions, and discrepancies in physician documentation. To illustrate these denials, here are some definitions:

• Sepsis 1: Systemic Inflammatory Response Syndrome (SIRS) plus known or suspected infection.
• Sepsis 2: 2 SIRS criteria plus known or suspected infection.
• Sepsis 3: Life-threatening organ dysfunction due to a dysregulated host response to infection (2 points or more in the Sequential Organ Failure Assessment [SOFA] score).

Insurance companies adopt various criteria, causing complexity for coders. It’s crucial for coders, Clinical Documentation Improvement (CDI) specialists, and physicians to be aware of specific coding and documentation guidelines outlined in contracts with insurers. These contracts often specify the sepsis definition to follow, affecting denial reasons mentioned later. Collaboration among coding, Health Information Management (HIM), and physicians is vital to understand contractual requirements for coding and documentation in healthcare records. The language used in contracts concerning sepsis diagnosis reporting is crucial for appealing denials.

Are sepsis denials solely the fault of coders? Not typically! The majority of sepsis denials stem from clinical audits questioning the clinical support for a physician’s sepsis diagnosis.

Denial Examples:

The majority of denials result from inadequate documentation or clinical indicators in medical records. Remember, even if coded according to physician documentation, lacking clinical indicators can lead to high chances of denials, impacting the entire facility.

To prevent sepsis denials:

Educate providers and CDI on necessary documentation elements, ensuring a comprehensive record that captures the severity of illness, signs, symptoms, workup findings, and treatment details. Align clinical signs and symptoms with the sepsis diagnosis rather than localized infections. Ensure consistent and complete documentation or send queries for clarification when needed. Collaborate among coders, CDI, and physicians for clear sepsis documentation.

Facilitate an escalation policy for records lacking clinical support before finalization. Stay updated on different sepsis criteria and payer-specific requirements outlined in contracts. Query at coding to avoid billing issues and conduct thorough record reviews beyond what denial letters highlight. Consider second-level reviews for clinical validation before billing. Appeal letters should encompass all supporting documentation and references.

Acknowledging differences in opinion when writing appeal letters is crucial. Remember, lacking clinical indicators despite physician documentation can lead to denials impacting the entire facility.