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Sepsis is considered one of the top reasons for claims denials on hospital bills. This Webinar will focus on what is needed to overcome assigning this diagnosis in error or without the appropriate supporting clinical diagnoses. We will dissect all the different versions of Sepsis (Sepsis I versus Sepsis II versus Sepsis III) parameters and look for common denominators that will hold up on review.

Overcoming cloned notes that create inconsistencies in the clinical picture will be a topic of discussion. Clinical and Coding Queries best practices will be addressed. The confusion stemming from meeting the newest Quality Measure protocol for suspected sepsis and how to avoid coding for the syndrome when it is just the protocol being initiated. Together we will write a letter to overturn a denial for sepsis.

Learning Objectives/Agenda

• Identify the features of the Sepsis Syndrome and how to identify them in the medical record
• Clarify the multiple Sepsis parameters and adopt what works to avoid denials
• Write clinically appropriate queries in a timely manner to clarify the diagnosis of Sepsis
• Review the Sepsis quality measure and how to differentiate it from an actual diagnosis of Sepsis
• Learn when and how to write an appeal letter to overturn a denial

Why is this topic important?

According to an industry Q&A/Survey published in CDI Week in 2024 respondents indicated Sepsis was the diagnosis responsible for over 85% of their denials. Denials management of this high profile/ high dollar diagnosis hinges on the documentation required to support clinical validation of Sepsis.

There are multiple versions of clinical parameters in play and coders, CDI professionals and providers really need to find a strategy that will identify what is required to bill a diagnosis of sepsis. Cloned notes, inconsistent documentation and lack of clinical evidence such as a positive culture, associated organ failure, and no treatment for either infection or an unstable clinical picture cause DRGs and payments to be overturned and returned.

Who would benefit from this topic?

• Emergency room coders
• Inpatient hospital coders
• CDI staff
• DRG Auditors
• Appeals staff
• Coding Educators

What is the presenter's background/expertise on this topic?

Nancy ha been a CDI / DRG Clinical Auditor/Coding Educator for a total of 8 years working in both rural and multiple urban university/Trauma 1 settings. She spent time working for a RAC and as a third party reviewer looking for DRG clinical validation of hospital bills and approximately 75 % were for Sepsis. She also spent a year as a DRG educator for a multi-hospital system with a University trauma 1 center and smaller affiliated hospitals, providing coding review and education on Sepsis and other diagnoses.

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