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The High Cost of Misunderstanding Sepsis: Clinical and Billing Challenges

June 2024

Marilyn Burgos, MS, CDMP - Marketing Manager

Sepsis is a critical and life-threatening issue that significantly impacts healthcare systems worldwide. It ranks high among the primary reasons for hospital admissions in the United States, making it one of the country's most costly healthcare challenges. Given its prevalence and economic impact, insurers often rigorously review and frequently reject claims related to sepsis.

Sepsis is notorious for being the main contributor to mortality and imposing vast economic burdens on health systems. The complexities in billing for sepsis stem from the assorted definitions of the condition and the evolving clinical markers that affect how it is documented and coded.

Let's explore a brief overview of Sepsis-3 criteria, the challenges they have created for billing and documentation, and the crucial role of education.

The introduction of the SOFA (Sequential [Sepsis-related] Organ Failure Assessment) score has been crucial in delineating organ dysfunction. The SOFA score thoroughly evaluates six vital organ systems, grading their functionality to pinpoint the severity of the condition.

The pivotal updates to sepsis classifications in 2017, known as Sepsis-3, were essential for equipping healthcare professionals with the necessary criteria to rapidly diagnose and treat this condition, emphasizing the importance of organ failure in its definition to enhance patient care. However, this evolution has led to confusion and variability in how sepsis is diagnosed, documented, and coded for billing purposes.

Most Sepsis-3 denials have occurred due to the following:

  • Inadequate documentation or absence of explicit clinical indicators.
  • Even with a definitive diagnosis from a physician, missing clinical signs often lead to claim denials.
  • Hurdles also exist in coding viral sepsis due to nonspecific coding options within the ICD-10-CM, complicating the coding process further.

Here's a deeper dive into the complexities of billing and documenting sepsis, emphasizing the difficulties caused by its evolving definition and clinical markers.

  • Clinically, sepsis can present with a wide array of signs and symptoms overlapping with other conditions, complicating accurate documentation.
  • Identifying organ dysfunction requires meticulous monitoring and interpretation of laboratory results and clinical data, which must then be accurately reflected in a patient's medical record.
  • Billing for sepsis treatment is further complicated by stringent requirements from insurance companies and Medicare for the justification of sepsis as a diagnosis. If the documentation is not precise or does not sufficiently illustrate the patient's condition as aligning with the current sepsis criteria, it can lead to claim denials. This can result in significant financial losses for healthcare providers who have already allocated considerable resources towards the patient's care.
  • SOFA scores are intended to provide more objective criteria for diagnosing sepsis. However, correctly converting clinical observations into SOFA scores and effectively communicating those findings through documentation is an intricate process. Reimbursement can hinge on these details, and any mismatch between the clinical picture and the documentation can trigger claim reviews and denials.

Additionally, coding has to consider not only the presence of sepsis but also the source of the infection and any associated organ dysfunctions or complications. Each must be charted comprehensively to capture the severity and complexity of the patient's condition.

Essentially, billing and documenting sepsis require exactness and a deep understanding of changing clinical guidelines and coding practices. These are necessary for healthcare providers to reconcile the clinical realities of sepsis with the administrative demands of accurately capturing and communicating the condition for billing purposes.

The Strategy of Clinical Documentation Improvement (CDI)

For clinical documentation improvement (CDI) specialists, the strategy includes sending a clinical validation query when documentation lacks sufficient evidence of sepsis. This inquiry aims to:

  • Clarify whether sepsis was present or ruled out.
  • Supported by clinical indicators from the current patient encounter.

The Power of Education and Training

The essential role of education and training cannot be overstated. Healthcare professionals, especially the clinical staff, need regular updates on the documentation standards to accurately depict the clinical scenario of sepsis, linking the signs of infection directly to organ dysfunction. For coding and CDI teams, in-depth training on the updated sepsis criteria and clinical guidelines is crucial. Since the SIRS criteria coupled with infection no longer suffice for coding sepsis, a deeper analysis for sepsis and related organ dysfunction is required. Studies have shown that enhancing the training of coders can notably improve the accuracy of sepsis coding, thereby reducing denials and ensuring a more accurate depiction of sepsis incidence in healthcare data.

Contact us today at 609-918-0990 or at to learn how education and training can improve the management of sepsis care, reduce financial losses, and improve patient outcomes.


A bit about the author:

Before diving into the world of marketing, Marilyn spent over 15 years working in various roles within the healthcare community. Her extensive experience in the field has provided her with valuable insights and a deep understanding of the industry. In addition, Marilyn's passion for sharing knowledge led her to coauthor a medical billing and coding book. Follow her on LinkedIn.

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