Sepsis-3 Denials

Download this tip

United Healthcare announced that beginning July 1, 2021, it will be performing pre-payment and post-payment reviews for sepsis using Sepsis-3 criteria. UHC has indicated the reviews will be based on The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).

Key concepts supported by the Sepsis-3 paper that may assist with defending the diagnosis of sepsis include:

  • “Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.” (1)
  • The SOFA score is a scoring system used to identify organ dysfunction in patients with sepsis and should not exclude the diagnosis of sepsis in patients with a SOFA score < 2.
    • “There are, as yet no simple and unambiguous clinical criteria or biological, imaging, or laboratory features that uniquely identify a septic patient.” (1)
    • “Neither qSOFA nor SOFA is intended to be a stand-alone definition of sepsis. It is crucial, however, that failure to meet 2 or more qSOFA or SOFA criteria should not lead to a deferral of investigation or treatment of infection or to a delay in any other aspect of care deemed necessary by the practitioners.” (1)
  • The risk of mortality for patients diagnosed with sepsis supports inpatient level of care.
    • “Even a modest degree of organ dysfunction when infection is first suspected is associated with an in-hospital mortality in excess of 10%.” (1)
    • “Patients with a SOFA score of 2 or more had an overall mortality risk of approximately 10% in a general hospital population with presumed infection.” (1)
  • “The baseline SOFA score should be assumed to be zero unless the patient is known to have preexisting (acute or chronic) organ dysfunction before the onset of infection.” (1)
  • Growth of bacteria from blood cultures or identification of the organism causing infection is not needed to support a diagnosis of sepsis.
    • “An added challenge is that infection is seldom confirmed microbiologically when treatment is started; even when microbiological tests are completed, culture-positive “sepsis” is observed in only 30% to 40% of cases.” (1)

Linking the infection to organ dysfunction is critically important! Link the UTI with the AKI

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3); Mervyn Singer, MD, FRCP1; Clifford S. Deutschman, MD, MS2; et al; JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

Download the complete tip, Sepsis-3 Denials.