Among the many types of denials from insurance companies that come across my desk, one I have been seeing more frequently is the “DRG denial.” This is where an insurance company will comb through the medical record of a claim and deny a specific “diagnosis related group,” or DRG. So, for example, a hospital will send a claim for a specific hospital stay, and then the insurance company will comb through the chart and then deny a specific diagnosis, such as “acute respiratory failure.”
Once, an insurance company actually denied the diagnosis of “acute respiratory failure” in a case of a teenage boy who suffered cardiac arrest at home and needed a ventilator in the hospital. When the treatment team finally got around to measuring the oxygen levels, after he was on a ventilator, his oxygen levels were great. So, the insurance company said there was “no evidence of respiratory failure in the medical record.” This was ridiculous, and the most egregious example of this type of denial. But, it happens, and it happens a lot.
One particular DRG denial with which commercial payers are having a field day is the sepsis denial. The definition of sepsis (previously known as septicemia) has gone through many iterations throughout the years. In the past, sepsis was defined as “a known or suspected infection along with two or more signs of the systemic inflammatory response syndrome, better known as SIRS.” This definition is still used by the Centers for Medicare and Medicaid Services (CMS) today.
In 2016, an International Consensus Group came together and re-defined sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” How do you define “life-threatening organ dysfunction”? They said that this can be operationalized by an increase in the SOFA score by 2 points of more, SOFA being “Sequential [Sepsis-related] Organ Failure Assessment.”
SOFA assigns a specific point value for dysfunction is six organ systems: mental status, oxygenation, blood pressure, bilirubin, platelet level, and renal function. The worse the organ failure, the higher the SOFA score. A normal, healthy human has a SOFA score of 0.
As a critical care physician, I understand why this change in the definition was made. Using the “old” definition of sepsis, which we call Sepsis-2, a patient with a urinary tract infection who has a fever and high heart rate has a diagnosis of “sepsis.” Yet, in clinical practice, this is really not sepsis. Sepsis is organ failure as a result of infection. A fever and high heart rate is not organ failure, it is a reaction of the body to inflammation.
If someone has a urinary tract infection and has renal failure and shock as a result, however, that is truly sepsis. The new definition of sepsis, called Sepsis-3, better encapsulates those patients who truly have sepsis. And word to the wise: if you were to call me up and say, “Hey Dr. Hassaballa, I can’t come to work today because I’m septic with a cold, a fever, and my heart rate is 105,” I would say, “Umm…that’s not sepsis. You better show up to work.”
This change in definition is not without controversy, and it does not help that CMS has one definition of sepsis (and holds hospitals to that definition) while the literature suggests another definition. Commercial payers have dived into this controversy head-on, and I have lost count of the number of DRG denials that come across my desk related to the definition of sepsis.
For example: a patient presents to the hospital with a pneumonia, and he has an elevated white blood cell count, a fever of 103, and a heart rate of 115 beats per minute. His blood pressure is normal, his kidney function is normal, he is awake and alert, he has no other organ failure. The doctor treating this patient, using Sepsis-2, diagnoses the patient with sepsis. The claim goes to the commercial insurance company, and they look through the chart and deny payment saying, “There is no evidence of sepsis in this record according to Sepsis-3.” Technically, they would be absolutely correct.
Now, they do these types of denials because, if there is no sepsis, the severity of illness related to the hospital stay decreases. And, with a lower severity of illness, the payment to the hospital will also become lower. In fact, many times, the insurance company will say in a letter, “We issued an overpayment on this claim. We looked at the record, and there was no evidence for sepsis. Thus, you owe us $10,000.”
That’s when I get the appeal, to argue against the allegation that there was no sepsis. Yet, if there is no organ failure, if there is no hypoxia, or shock, or renal failure, or high bilirubin, or altered mental status, or low platelet count, then there really is no sepsis according to Sepsis-3. And, therefore, my appeal will be inherently weak, because Sepsis-2 is not the most recent, evidence-based definition for sepsis. It just is not.
So how to avoid these denials? In short: check the face sheet.
The face sheet is the part of the chart that has the demographic and insurance information for the patient. If the patient has commercial insurance or has a Medicare Advantage plan, I will bet you dollars to donuts that they will be using Sepsis-3 as their definition for sepsis (and they are not wrong to do so). If the patient has traditional Medicare, however, the definition for is sepsis is Sepsis-2, which is SIRS plus infection.
Yes, it is confusing. Yes, it is quirky. Yes, it is annoying. It is the way of the world in 2022, and we clinicians have to become more sophisticated in our understanding of how our healthcare world operates in the United States. Complaining about it and saying, “Well this is ridiculous” does not change the reality. If we just spend the extra ten seconds and look at the face sheet, we can save ourselves a whole lot of pain and suffering later by avoiding a sepsis DRG denial. It is truly time well-spent.