When Erica Remer, M.D., was a young physician, the way she knew a patient with an infection had sepsis was “you walked into the room and got the sinking feeling the person would die from this infection.” As she got older, more formal protocols for diagnosing sepsis were developed, notably Sepsis-2, and more recently, Sepsis-3, which mandated the presence of organ dysfunction. But they’re more than clinical tools to help detect sepsis. The tug of war between Sepsis-2 and Sepsis-3 is at the heart of Medicare Advantage and other payer claim denials. The plans may downcode MS-DRGs unless patients have all the hallmarks of Sepsis-3, which some hospitals and physicians feel leaves too many cases out. They may stick with Sep-2, although there is movement toward Sep-3, experts say.
Remer thinks the payers are right for a change, although Sepsis-3 is more restrictive. “The sine qua non of sepsis is organ dysfunction,” she said.
But it’s a complicated and expensive picture because sepsis is probably the top diagnosis of clinical validation, said Denise Wilson, senior vice president of PayerWatch in Towson, Maryland. “Sep-3 made it a lot easier for the payers to pick that as a target.” The downcoding driven by Sepsis-3 continues to be “a pervasive problem” nationally, said Jolene Calla, vice president of health care finance and insurance at the Hospital and Healthsystem Association of Pennsylvania (HAP). She said the protocol was never meant to be a basis for payment.
Sepsis-2 is defined by the presence of systemic inflammatory response syndrome (SIRS) plus infection, according to the Society of Critical Care Medicine’s (SCCM) 1991 consensus definition, known as Sepsis-1, which continued with its 2001 Sepsis-2 definition and remained through 2015. In 2016, SCCM’s Sepsis Definitions Task Force published Sepsis-3, which defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” They recommended the use of sequential organ failure assessment (SOFA) scores to determine organ dysfunction.
