Updated on: November 28, 2016

It’s Official: CMS Does not Support Third Definition of Sepsis

Original story posted on: August 8, 2016
Last spring I wrote about the new third definition of sepsis with a fair amount of enthusiasm and excitement. From my perspective, this new definition was the answer to the ever-present criticism of sepsis criteria – namely, the notion that people who meet the criteria often are not septic. The Centers for Medicare & Medicaid Services (CMS) seemed to share this view, entering into agreements with Recovery Audit Contractors (RACs) that delighted in informing physicians and hospitals alike that a patient previously diagnosed as septic could not be, because their symptoms were vague and could have been caused by too many things. I was delighted that we might finally have criteria likely to produce fewer false positive cases while providing a more reliable data set. The fact that it might send the auditors packing was a bonus. The third definition of sepsis held that promise – or so I thought.

The honeymoon did not last long, as the criticism about the new definition surfaced nearly immediately after it was published. Initially it seemed to be a knee-jerk reaction, as I noticed that the surviving sepsis campaign members as well as clinical documentation specialist organizations seemed willing to embrace the new definitions. What I did not know, however, was that the level of resistance that would come about by both providers and CMS would be so stiff.

CMS, having just initiated their early management quality measure via the Inpatient Prospective Payment System (IPPS) final rule covering the first definition of sepsis, quite predictably would have a decision to make regarding their work with the National Quality Forum and Henry Ford Hospital. That decision has surfaced in the form of a letter published in the Journal of the American Medical Association (JAMA) on July 26. In short, they are not making any modifications to their first definition of sepsis, quality metrics, or recommended clinical processes of care. 

Reasons vary, and in retrospect, they are quite understandable. General familiarity with the first definition of sepsis tops the list. Considering the fact that early identification and treatment of standardized infection ratios (SIRs) associated with infection has shown a 15-year trend towards reduction in sepsis mortality, CMS has shown a genuine concern that a lack of confirmation of organ failure (criteria for the third definition) could have the unintended consequence of delaying lifesaving therapy. For the moment, let us just ignore the fact that CMS effectively denies claims for sepsis when such positive outcomes occur early in an admission through aggressive therapy.

The consensus seems to be that clinical validation, peer review, and an in-depth analysis of the methodology of the original study are in order. 

For the time being, we will not be seeing any changes in the coding guidelines, ICD-10 codes, CMS policy, or advice provided via Coding Clinic. Interestingly enough, clients have informed me that some commercial insurance companies are using the new criteria to deny claims on patients diagnosed with sepsis via the first definition. If the thought of having to determine if sepsis can be diagnosed based on payor requirements horrifies you, I assure you that you are not alone. Score another point for the endless crusade to deny claims based on a shell game of “if x happens with or without y, we have a loophole that says we do not have to cover the beneficiary.”

The good news: CMS purportedly will not be allowing RACs to use similar tactics. For now, they will have to stick with “SIRS criteria are not specific to sepsis” in order to “recover improper payments” from hospitals and providers. Now would be a good moment to point out CMS’s sudden love of the original sepsis criteria as having “underwent more than eight years of development and critical review” while being supported by a large body of clinical evidence. It is a bit comical to me that they contract with auditors that are apparently unaware of all of those years of development and the large body of evidence supporting it.

According to CMS.gov, CMS is in an active procurement process for its next round of fee-for-service RAC program contracts as of June 2. Let’s hope they get a few that can follow the clinical indicators beyond what is scratched out on a preprinted cheat sheet this time around.

About the Author

Allen R. Frady is a senior consultant for Optum360. His experience includes areas in management, implementation, education and clinical practice.  With 20 years in healthcare, he provides clients assistance in the areas of documentation, program implementation and compliance.  His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Allen R. Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

With 20 years in healthcare, Allen R. Frady provides clients assistance in the areas of documentation, program implementation and compliance. His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.

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