As I do my appeal letter work, I frequently come across a justification for the denial that says something like this: “A payer may use its own criteria to establish a diagnosis.” And the cite an AHA Coding Clinics article from Q4 2016, p. 149. One of the most common diagnoses they deny using this article is sepsis.
Why sepsis?
Because it is a very high-risk disease, and it dramatically increases the severity of illness and the subsequent DRG payment to the hospital. If they payer denies this diagnosis, then they come to the hospital and say, “We overpaid you, and you owe us $5000.” It is super annoying and frustrating.
Now, previously we discussed this AHA Coding Clinics article and how they are (likely deliberately) misquoting this article to justify denying high risk DRGs. With sepsis, the payers do not tell you that that very same article specifically cited the new Sepsis-3 guidelines in their article. I have reproduced the section here in its entirety (emphasis mine):
“While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria. In other words, regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same—as long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned. Coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded. For example, if the physician documents sepsis and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician’s diagnosis, that is a clinical issue, but it is not a coding error. By the same token, coders shouldn’t be coding sepsis in the absence of physician documentation because they believe the patient meets sepsis clinical criteria. A facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.”
So the article clearly says that if the physician feels the patient has sepsis and documents this in the record, then sepsis should be coded (and then paid for). Full stop. This article clearly does not authorize the payer to come up with their own criteria for a particular diagnosis.
Will this stop insurance companies from continuing to do this? Probably not. At the same time, the best way we physicians can defend against this is through proper documentation. We need to take the time and properly document why the patient, in our clinical judgement, has sepsis. When we fail to do this, then it gives payers an opening to deny DRGs and then recoup payment. It is time very well spent.
