Sepsis: Diagnosis, Data, and Revenue Cycle

Tip of the Week:

Want to see a workflow within Epic, including screenshots?

Google it. Example search term : "epic" "tip sheet" “sepsis”

You’ll see numerous examples like this one.

Source: Henry Ford Health

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Table of Contents:

#1 What is sepsis?

#2 Who are the clinicians treating sepsis?

#3 How is sepsis diagnosed? Which lab orders are placed?

#4 How is sepsis treated?

#5 How does the revenue cycle work for sepsis?

#6 Thoughts and Gratitude

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#1 What is sepsis?

Sepsis is not as easy to define as other conditions.

Per the CDC , “Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body.”

Sepsis causes 1 in 3 hospital deaths in the US and costs over $62B annually. (Source: Sepsis Alliance )

It can start in numerous parts of the body, with numerous types of infections, and can cause dysfunction across numerous types of organs.

That’s a lot harder to define and diagnose than conditions that require a single lab test, like hyperlipidemia (high cholesterol).

Source: World Sepsis Day

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#2 Who are the clinicians treating sepsis?

Clinicians in an emergency department triage their patients to identify and prioritize their needs. If they have sepsis, the patients are likely admitted into the hospital for additional care because it is a life threatening condition.

Clinicians on an inpatient floor are trying to stabilize the patient’s health so they can be healthy enough to be discharged (leave the hospital). Each patient has a principal diagnosis, which is the main reason they are in a bed receiving 24/7 care. That’s the clinicians’ top priority.

Sepsis is the most common “top priority”.

Among all inpatient principal diagnoses, sepsis is #1 in both frequency and total expenditure (not including maternal or neonatal stays). It’s twice as common as the next most common principal diagnosis (heart failure) and has one of the highest average costs per stay ($18,700).

Source: Healthcare Cost and Utilization Project , 2018

#3 How is sepsis diagnosed? Which lab orders are placed?

One of the standards for diagnosing sepsis is called SOFA (Sequential Organ Failure Assessment). It emphasizes the bodily systems involved with sepsis and some of the diagnostics to evaluate those systems.

Source: ACDIS

Lab results provide key data for the hospital to identify sepsis.

Complete Blood Count / CBC (Does the patient have elevated white blood cell levels? Or reduced platelets? Signs of infection?)

Bilirubin (Is the liver filtering bilirubin from the blood? Is there potential liver dysfunction due to infection?)

Creatinine (Are the kidneys filtering creatinine from the blood? Is there potential kidney dysfunction due to infection?)

Lactate (Are the kidneys and liver filtering lactic acid from the blood? Do the kidneys and liver have dysfunction due to infection?)

Blood Culture (Does the patient have a bacterial infection in their blood?)

#4 How is sepsis treated?

Each hospital has its own sepsis protocols. Some are defined internally. Some originate from the Surviving Sepsis Campaign . (The 3-hour and 6-hour recommendations used below by Henry Ford Health are from the 2012 iteration of that campaign .)

Other protocols are defined on a federal level, like the CMS’ “FY 2024 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Rule” (CMS-1785 for short) which incentivizes best practices to keep sepsis patients alive and healthy.

Common treatments include:

Antibiotics (To treat the infection)

IV Fluids (To maintain blood pressure)

Vasopressors (To maintain blood pressure)

Source: Mayo Clinic

Source: Henry Ford Health

And all of these steps are documented within the EMR (electronic medical record) to ensure that all healthcare protocols are followed, to provide legal proof of care, to improve communication between clinicians, and to provide supporting documentation when the hospital submits a claim to be paid by Medicare/Medicaid/private insurers.

#5 How does the revenue cycle work for sepsis?

The inpatient revenue cycle has some fundamental parts, regardless of diagnosis: patient registration, charge capture, utilization review, coding, claim submission, remittance from the patient’s insurance, patient collections and more.

Sepsis billing stands out with its coding and clinical documentation improvement.

It’s complicated.

It’s expensive.

And there is a challenging dynamic between hospitals and payers where their financial interests clash, especially with $60B on the line.

It’s hard to get paid for treating sepsis if a hospital and payers don’t even agree on the definition of sepsis. Standardized definition and diagnosis of sepsis have been evolving and disputed since the 1990s. (e.g. Sepsis-2.5 Resolving Conflicts Between Payers and Providers, NIH )

Source: Sepsis Program Optimization , Erkan Hassan, Pharm. D., FCCM

Not even all payers share definitions of what sepsis is, so a hospital needs to fulfill different criteria to get paid based on the patient’s insurance.

Source: ACDIS , Heather Luton, BSN, RN, CCDS

So much of this comes down to coding and clinical documentation improvement.

The primary billing codes assigned to the inpatient visit are ICD-10s (diagnoses), CPTs (Procedures. What did the hospital do?), HCPCS (Procedures. What did the hospital do?), and DRGs (Diagnosis Related Groups).

A coder would know that coding for sepsis-3 for a patient with private insurance would typically include three diagnosis codes, the primary diagnosis (which may indicate the type of infection), a secondary diagnosis to indicate whether there was septic shock or not, and another secondary diagnosis to indicate which organ has dysfunction. (Source: Pinnacle )

Example:

A41.9 – Sepsis, unspecified organism

R65.20 – Severe sepsis without septic shock

J96.01 – Acute respiratory failure with hypoxia

DRGs are defined by CMS. And for sepsis, it comes down to whether MV (mechanical ventilation) has been used for over 4 days and whether there are MCCs (major complications / comorbidities).

Source: CMS

This is where clinical documentation improvement (CDI) comes in. These are typically composed of CDI nurses with expertise in inpatient care who evaluate the medical record and can find gaps in the documentation. For example the DRG difference between a clinician typing in “Possible sepsis.” vs “The patient has sepsis.” can be worth $6,766.15. (Source: AAPC ) These nurses can follow up with the inpatient clinicians to confirm the billing is accurate.

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#6 Next Steps and Gratitude

Sepsis is one of the most difficult challenges of our time. It affects millions of patients, numerous bodily systems, and is resource intensive to treat.

I find it best to point you to the experts who I learned from while writing this piece and whose material I recommend that you read.

Thank you to Alexis Jaramillo Cartagena, PhD for 15-years of friendship, your important work at 纪念斯隆-凯特琳癌症中心 , and for inspiring this writing by telling me about our current shortage of blood culture supplies.

Source: LinkedIn

Thank you to Heather Luton . Your ACDIS piece on sepsis and CDI at Prisma Health was incredibly helpful and succinct. I really appreciated the real world evidence that you gave for how your team is addressing this challenge.

Thank you to Bishal Gyawali , Karan Ramakrishna , and Amit S Dhamoon. Your research article on sepsis diagnostics and therapies describes the condition so well. You remind us why this space matters.

Thank you to Jess Schlapper, CPC, CPCO, CEDC, CRC for clarifying which diagnosis codes are used for sepsis and why they should be used.

Thank you to Jill Julanko for emphasizing the hospital value that is generated from using the correct codes.