Knowledge Base Article

“Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.”

• The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

U.S. Department of Health and Human Services (HHS) Study

According to a February 14, 2020 HHS News Release, an HHS study of sepsis cases found that “U.S. hospitals saw a 40 percent increase in the rate of Medicare beneficiaries hospitalized with sepsis over the past seven years, and in just 2018 had an estimated cost to Medicare of more than $41.5 billion.”

About the Data

• Data analyzed was for claims from 2012 through 2018.
• Data analysis included traditional Fee-for-Service and Medicare Advantage enrollees “to explore the burden of sepsis in highly impacted populations including older Americans, those with end-stage renal disease, and those who depend on both Medicare and Medicaid.”
• Data included more than 9.5 million inpatient hospital admissions.
• This is the largest sepsis study based on contemporary Medicare data to be published in the United States.

Study Findings

• Researchers found no correlation between the rise in sepsis cases and the number of American seniors enrolling in Medicare. In fact, the 40% increase in sepsis-related hospital admissions among beneficiaries was almost double the 22% increase in Medicare enrollment rates.
• More patients presented to a hospital with sepsis than developed sepsis after being admitted. The news release noted this to be “a possible indicator of success for CMS efforts to reduce hospital-based cases of sepsis.”
• However, two-thirds of the patients had had a medical encounter in the week prior to presenting for hospitalization which “represents an opportunity for improved education and awareness among patients and healthcare providers, as well as the need for diagnostics to detect sepsis early.”
  

The Cost of Treating Sepsis

The cost per Medicare beneficiary decreased between 2012 and 2018. However, due to the increasing volume in cases of sepsis, HHS estimated an overall increase in Medicare spending from $27.7 billion in 2012 to greater than $41.5 billion in 2018 for inpatient hospitalizations and subsequent skilled nursing facility (SNF) care. Researchers found overall costs rose 12-14% every two years and subsequently anticipated inpatient and SNF care for sepsis in 2019 may exceed $62 billion.

Steps to Improved Identification and Treatment of Sepsis

According to Rick Bright, Ph.D., a study author, HHS deputy assistant secretary for preparedness and response (ASPR) and director of the Biomedical Advanced Research Development Authority (BARDA) at ASPR, “to save lives in public health emergencies, we must solve sepsis…solving sepsis requires working together. Because of the health security implications, we are taking a holistic approach to this national threat.” Examples cited in the news release of what is being done includes:

• A partnership to develop adoption of new technologies to detect sepsis earlier as well as to predict and identify the severity of the infections.
• Implementation of the CMS inpatient bundled sepsis measure as part of the Inpatient Quality Hospital Reporting Program.
• The 2019 IPPS Final Rule finalized “an expanded pathway for certain new antibiotics to more quickly receive additional Medicare payments and to increase payments for them.”
• The Centers for Disease Control and Prevention (CDC) has a Get Ahead of Sepsis Campaign and has made available educational information for healthcare professionals, patients and the general public. https://www.cdc.gov/sepsis/index.html

New Pediatric Sepsis Guidance

Earlier this month the Surviving Sepsis Campaign made available the first edition Guidelines for Pediatric Patients. This guidance includes an initial resuscitation algorithm that provides a guide for systematic screening for sepsis in children and guidance for care in settings both with and without intensive care services. 

Sepsis in the Spotlight

The HHS study validates the growing number of Medicare Contractors auditing sepsis inpatient claims including the following:

• Medicare Administrative Contractors: Earlier this month Palmetto GBA, the Jurisdiction M MAC, added DRGs 871 and 872 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with and without MCC respectively). An article titled Diagnosing Sepsis and Related Conditions provides tips when coding sepsis is available on their website.
• Comprehensive Error Rate Testing (CERT): The 2019 CERT Report lists Septicemia (DRGs 871 and 872) as being in the Top 20 Service Types with the highest improper payment rates for Part A IPPS Hospitals. While the improper payment rate was relatively low at 3.1%. All of the errors were due to incorrect coding.
• Recovery Auditors: RAC approved issue 0001 – Inpatient Hospital MS-DRG Coding Validation allows the RACs to review all MS-DRGs to validate MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. Note, clinical validation is not permitted as part of this approved issue.

Moving Forward

Do you know how well your hospital is managing this patient population? Have you looked at the sepsis measure available on Hospital Compare to see how you rank against your state and the nation? In spite of the Sepsis 2 and Sepsis 3 definitions, this information is available for the public to view, you need to know how you compare.

Sepsis is also a Target Area on the PEPPER Report. Is your hospital an outlier? If so, have you performed internal reviews to validate that documentation in your records supports the diagnosis of sepsis?

The data shows sepsis is a growing and expensive problem. It is imperative for hospitals to provide timely care and code the claim correctly.