Insurance companies will look for every way possible to take back reimbursements for care, especially in severe (and costly) infection cases like sepsis. That means it’s up to us, the people who review payer decisions, to defend you and Salem Health for what should be covered.
Here’s some critical advice from your health information management folks:
Is it sepsis? Salem Health’s definition does not align with the new “Sepsis 3” criteria. This discrepancy leads to many claims denials. We use our definition to fight this, but could use your help. Along with listing any clinical criteria for sepsis, it is helpful to describe how the patient appeared septic.
Example: When Dr. A documents “alert and oriented, non-toxic, sitting up conversing with family,” it doesn’t paint a picture of sepsis. Then Dr. B documents “febrile, shortness of breath, skin moist,” which creates conflicting documentation that raises another red flag to auditors. Can the clinical criteria be assigned solely to the infectious process being treated?
These discrepancies are significant grounds for a denial. If a patient has pneumonia, we’ll see shortness of breath, likely with fever and tachycardia. What differentiates the case to justify sepsis is what payers are attacking the most: Can these clinical indicators be “just pneumonia”? What makes this sepsis? This is where the descriptors come in -- leukocytosis with left shift, febrile to 101 with diaphoresis, pale, weak, obtunded. Is there organ failure? If so, spell it out and link it to the sepsis. Is there encephalopathy? It must be clearly stated and linked to the sepsis.
Be clear with all the details that point to sepsis. Is if there organ failure? Is it due to sepsis? You must link it if you think the sepsis is the cause of the organ failure. Is there hypotension? Is it shock due to sepsis? If so, state that.
We will continue to fight the fight, and look to you to provide documentation that clinically supports the facts and basis of your treatment.
Thanks for all you do to help us!