Uncovering Sepsis as a Root Cause of Coding Mishaps

by Tiffany Ferguson, LMSW, CMAC, ACM
Published on Feb 13, 2023

This article appeared on RACmonitor.com on February 13, 2023

Some vendors will need education as to what criteria need applying.

A recent conversation developed among a client and a vendor that has a longstanding relationship with said client, with the topic at hand being documentation improvement efforts to increase case mix index (CMI) and diagnosis capture for clinical documentation integrity (CDI). 

In the utilization review (UR) world, I feel that it is vital to partner with CDI, because documentation is so important to both of us. Why list the diagnoses in the record if you fail to prove the medical necessity for treatment? CDI and UR should be in concert to ensure accuracy of the medical record to justify reimbursement and medical necessity for the care being provided.

During our discussion with the vendor, I raised some concerns we are seeing related to DRG downgrades, particularly associated with sepsis. This was news to the vendor, as they had only been focusing on Medicare and not contractual practices. I then asked the question of what their recommendations for sepsis were, and the answer was that “we strictly follow SIRS (systemic inflammatory response syndrome) criteria for diagnosis of sepsis.” 

At that moment, I must have channeled Dr. Erica Remer, because I then made the connection of why the Program for Evaluating Payment Patterns Electronic Report (PEPPER) showed outlier trends centered on coding, particularly for sepsis, as well as continued DRG issues that were masked under “lack of authorization,” “medical necessity,” and “clinical validation” denials or downgrades. 

When I asked if they had reviewed the client’s PEPPER, I was looked at as if I had two heads. At this point I realized that our journey to alignment was going to be a little bit longer than I had realized. But I decided to start with a generic example: a patient arrives in the hospital with all the evidence of an infection, meeting SIRS criteria. Sepsis is the working diagnosis while we evaluate what is going on; however, by day 2, it has been determined that the principal diagnosis was streptococcal pneumonia – yet the providers continued to copy and paste “likely sepsis.”

The chart is coded, billed, and then the denial comes, and the payer says, essentially, “we will pay you for streptococcal pneumonia, but we don’t think sepsis was clinically valid.” The finance people may think you have lost money, but the reality is that the patient belonged in the pneumonia DRG to begin with. 

Adjusting the principal diagnosis proactively will avoid having to expend the time and money to assess an erroneous denial on the back end. And pneumonia justified medical necessity just fine. 

Programming note: Listen to Tiffany Ferguson’s live reporting every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.