As we reflect on the transformation into spring, with large parts of the country still confronted by temperatures in the mid-30s at night and days when temperatures creep up into the high 70s, we are reminded of the profound disparity that was created between physicians and coders when the Society of Critical Care Medicine (SCCM) updated its sepsis definitions in 2016.
While the industry largely welcomed new, clear, and evidence-based criteria, coders were left constrained by outdated sepsis definitions and coding guidelines. Official coding guidelines still have not been updated to align with the new SCCM sepsis criteria, colloquially referred to as Sepsis-3.
These differences in definition have led to increases in payor denials for sepsis cases, especially in short stays. Nearly every sepsis inpatient claim of less than 72 hours – Medicare, Medicaid, and third-party commercial – is being audited, and in many cases, denied.
With revenue at risk, now is the time for health information management (HIM) and clinical documentation improvement (CDI) leaders to up their game with sepsis. Awareness and process improvement is essential to build consistency across clinical and financial departments, given the new definitions and criteria.
To successfully shift from the sepsis indicators of today to the SCCM criteria of tomorrow, hospitals must recognize the present-day impact on coders while also building bridges through education and monitoring. This article provides practical tactics and logical advice to do just that.