Most payers are using Sepsis-3 guidelines in their audits without acknowledging it, leaving the door open for hospitals to appeal claim denials using the signs and symptoms of systemic inflammatory response syndrome (SIRS) plus infection, which is Sepsis-2.

“Think outside the box a little,” said Denise Wilson, vice president of Intersect Healthcare + AppealMasters in Towson, Maryland, at a Jan. 23 webinar sponsored by the company. “Most payers are looking for Sepsis-3 criteria in their audits/denials, but that doesn’t mean the provider can’t or shouldn’t argue that the use of Sepsis-2 criteria constitutes a valid sepsis diagnosis.”

Hospitals should do whatever they can that’s appropriate to support the diagnosis because it’s very common and vulnerable to claim denials. For example, last year at a 22-hospital system, 43% of clinical validation denials she was aware of were for sepsis.

Sepsis is the talk of the town partly because physicians, payers and hospitals don’t always agree how best to diagnose it. Some physicians use the presence of systemic inflammatory response syndrome to diagnose sepsis based on 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. But in 2016, the 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” (RMC 5/22/17, p. 1). They recommend the use of the sequential organ failure assessment (SOFA) scores to determine organ dysfunction.