Successfully Appealing Clinical Validation and Coding Issues in Sepsis

Health information professionals have been seeing an uptick in sepsis denials. “It’s hard to say why … but most likely this is due to the multiple sets of criteria for the diagnosis of sepsis, the change in definition of sepsis, as well as physician documentation,”¹ says Kim Carrier, RHIT, CDIP, CCS, CCS-P, a director of coding quality assurance and an AHIMA-approved ICD-10-CM/PCS trainer. A robust clinical validation process can help prevent this issue. A clearly documented correlation between organ dysfunction and sepsis can result in the overturning of a sepsis denial or even the prevention of a potential denial. The clinical validation process is beneficial for clinical documentation integrity, the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, and denial prevention.

When physicians say a patient has an infection, they mean the patient has an invasion of the sterile tissue in the body by organisms. For example, this could be an invasion of the lungs that causes pneumonia or an invasion of the skin causing cellulitis. When physicians say a patient has bacteremia, they mean the patient has bacteria in the blood.

“Asymptomatic bacteremia can occur in normal daily activities such as conducting oral hygiene and after minor medical procedures,” write David A. Smith and Sara M. Nehring.² “In a healthy person, these clinically benign infections are transient and cause no further sequelae. However, when immune response mechanisms fail or become overwhelmed, bacteremia becomes a bloodstream infection that can evolve into many clinical spectrums and is differentiated as septicemia.”

Sepsis is when organ dysfunction occurs due to infection. It could be due to a local infection like pneumonia; it could also be due to a systemic infection like bacteremia. But any time an infection causes organ dysfunction diffusely in the body, it’s called sepsis. It’s a specific type of reaction to infection.

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. This definition of sepsis, known as Sepsis-3, emphasizes the primacy of the non-homeostatic host response to infection, the considerably higher potential lethality (when compared with that of a straightforward infection), and the need for urgent recognition.³

Based on Sepsis-3 criteria, organ dysfunction can be identified as an acute change in the total Sequential Organ Failure Assessment (SOFA) score of more than two points consequent to the infection. The baseline SOFA score can be assumed to be zero in patients not known to have preexisting organ dysfunction.⁴

One of the ways that organ dysfunction in sepsis can present is in the lungs; patients can develop acute respiratory distress syndrome (ARDS). In terms of hematology, patients with sepsis often develop reduced blood counts, and they can have low platelets or anemia. Patients with sepsis often have liver abnormalities; for example, their aspartate transaminase (AST) and alanine transaminase (ALT) will increase.

Sometimes patients can even develop liver failure, with problems like underproduction of albumin or clotting factors. In the kidneys, sepsis often leads to acute renal failure. In the brain, it often leads to encephalopathy. And in the cardiovascular system, it can lead to hypotension and shock. When the patient has sepsis and hypotension or shock, it’s called septic shock.

There is not a universally agreed-upon definition of the clinical features that define sepsis, and part of the reason for this is that it’s often difficult to define when organ dysfunction is specifically caused by infection and when it’s caused by another problem that is also occurring in patients who have an infection. Thus, the physician’s documentation must make the connection that the abnormal clinical values that support the organ dysfunction are a result of the sepsis. A clearly documented correlation between organ dysfunction and sepsis will very often result in an overturn of a clinical validation sepsis denial.⁵ Sepsis-induced organ dysfunction may be occult; therefore, its presence should be considered in any patient presenting with infection. Conversely, unrecognized infection may be the cause of new-onset organ dysfunction. Any unexplained organ dysfunction should thus raise the possibility of underlying infection.⁶

Case Scenario

Clinical validation queries are one potential tool to use in overturning clinical denials. This case scenario is an example where a clinical validation query was very helpful in overturning a denial.

A 62-year-old morbidly obese patient with a medical history of chronic heart failure, hyperlipidemia, hypertriglyceridemia, hypertension, obstructive sleep apnea, chronic obstructive pulmonary disease, and Type 2 diabetes came in the hospital with sepsis due to pneumonia. The admitting physician listed the following diagnosis on the discharge summary:

Sepsis, PNA, AKI, HF, DM type 2, HTN, OSA, COPD, hyperlipidemia, and hypertriglyceridemia.

SIRS criteria: HR 114, RR 42, Lactate 3.5, T=100.6 F; WBC 14000

C-reactive protein 35, Procalcitonin 3.9

Creatinine: Day 1: 1.5; Day 2: 1.8 (previously normal)

Bilirubin 3.2

Sample Clinical Validation Query

Dear Dr. Smith,

You have indicated within your discharge summary that the patient was admitted for sepsis in the presence of pneumonia. SIRS criteria were met on admission: HR 114; RR: 42; T=100.6 F; WBC 14000. On admit, the patient had a creatinine of 1.5 with an increase to 1.8 on hospital day two.

Based on your medical judgment, please review the documentation pertaining to sepsis and further clarify the condition you monitored and treated.

• Sepsis with organ dysfunction of AKI due to PNA.
• AKI unrelated to sepsis
• Other
• Clinically unable to determine

The physician’s response was “Sepsis with organ dysfunction of AKI due to PNA” POA: Y.

The payer subsequently denied this case.

Payer Denial Rationale

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Our insurance company requires the medical record to meet the following guidelines for sepsis:

• Documented infection, which can be presumed or confirmed; and
• Presence of acute organ dysfunction or failure due to the infection or sepsis; and
• Based on the causative organism (known or presumed), appropriate pharmacotherapy is initiated.

There was no remote organ failure secondary to infection reflected on the documentation.

The healthcare facility used the validation query in the appeal letter, and the denial was successfully overturned.

Appeal Response

A 62-year-old morbidly obese patient with a medical history of chronic heart failure, hyperlipidemia, hypertriglyceridemia, HTN, OSA, COPD, and DM type 2 came in the hospital with sepsis due to pneumonia. The admitting physician listed the following diagnosis on the discharge summary: Sepsis, PNA, AKI, HF, DM type 2, HTN, OSA, COPD, hyperlipidemia, and hypertriglyceridemia.

SIRS criteria: HR 114, RR 42, Lactate 3.5, T=100.6 F; WBC 14000

C-reactive protein 35, Procalcitonin 3.9

Creatinine: Day 1: 1.5; Day 2: 1.8 (previously normal)

Bilirubin 3.2

He had an infectious source of pneumonia with 4/4 SIRS criteria that was accompanied by AKI. On admission, the attending acknowledged patient came in with “sepsis with organ dysfunction of AKI due to PNA.” With these findings, the patients needed treatment with IV antibiotics and fluids.

Final Thoughts

When reviewing sepsis denials, clinical documentation integrity professionals should look for consistent physician documentation in the medical record establishing the true clinical evidence by which sepsis is diagnosed, monitored, and treated.

Notes

1. Carrier, K. 2019. “Why are so many sepsis records denied?” https://www.hiacode.com/education/reasons-for-denials-and-prevention-for-sepsis.
2. Smith, D., Nehring, S. 2020. “Bacteremia.” StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK441979/
3. Singer et al. 2016. “The Third International Consensus Definition for Sepsis and Sepsis Septic Shock.” JAMA. https://jamanetwork.com/journals/jama/fullarticle/2492881.
4. Ibid.
5. Wilson, D. 2019. “Appealing Clinical Validation Denials in the Era of Sepsis-3.” ICD10monitor. https://www.icd10monitor.com/appealing-clinical-validation-denials-in-the-era-of-sepsis-3.
6. Singer et al.

Alba Kuqi (albakuqi88@gmail.com) is an ACDIS Leadership Council member, PHIMA member, American Urological Association member, and an AHIMA Foundation Research Network volunteer.