OIG to Begin Claims Analysis of Sepsis-2; Writing on the Wall for Adoption of Sepsis-3

By Brian Murphy

Uh-oh, sepsis-2 defenders, the Office of Inspector General (OIG) might be coming for you.

We have a new entry in the OIG Work Plan, “Medicare Inpatient Hospital Billing for Sepsis.” It reads:

Sepsis is the body’s extreme response to an infection. It is a life-threatening, emergency medical issue that often progresses quickly and responds best to early intervention. The definition of and guidance for sepsis have changed over the years in attempts to identify it more accurately. The definition of sepsis was updated in 2016 by an international task force to better differentiate sepsis from a general infection. This narrower definition is widely recognized by groups such as the World Health Organization. However, CMS and CDC currently recognize an older, broader definition. Sepsis is a frequently billed diagnosis in Medicare. There are concerns that hospitals may be taking advantage of this broader definition, as they have a financial incentive to do so. This study will analyze Medicare claims to assess patterns in the inpatient hospital billing of sepsis in 2023 and describe how the billing of sepsis varied among hospitals. We will also estimate the costs to Medicare associated with using the broader, rather than the narrower, definition of sepsis.

(See link below)

It is not clear from me reading this that hospital financial recoupments are coming. The OIG seems to be conducting a broad claims review for CMS’ consideration.

But the way it’s worded seems to be a gentle push for CMS and hospitals to adopt sepsis-3.

Would love your thoughts.

For years most hospitals used sepsis-2 criteria. Many still do. Sepsis-2 is defined as a known or suspected infection plus two or more SIRS (Systemic Inflammatory Response Syndrome) criteria. These are usually described as:

  • Fever or hypothermia
  • Tachycardia
  • Tachypnea
  • Leukocytosis or leukopenia

Infection plus two of these was considered enough to meet the definition of sepsis-2 and code it. But many thought this was too broad and led to overdiagnosis.

That changed in 2016. An international team of experts released a paper on sepsis-3, which revised the definition to “a life-threatening organ dysfunction caused by a dysregulated host response to infection.”

While some of have embraced this new definition, others have argued that sepsis-3 raises the bar too high and is not well-suited for early detection, key to staving off long hospital stays, longer recovery, and death. Some hospitals claim sepsis-2 is a better mechanism for early detection of this life-threatening condition. They don’t dispute Sepsis-3, but consider it more suitable for capturing severe sepsis.

Early detection is critical, and hospitals (and EHR vendors like Epic) are investing considerable resources into the endeavor. I would hate to see these efforts stunted. Perhaps what we need is a new MS-DRG or other mechanism for capturing the costs of early intervention, intensive measures to knock out suspected infections before they blossom into full life and death survival.

If hospitals should shore up their medical records for (possible) audit, the OIG must be ready for pushback. A few years ago it lost a well-publicized case for challenging severe malnutrition, on every count, because the independent auditors it used to perform the record reviews were not up to snuff clinically, and did not use a coherent, up-to-date definition.

The OIG has that on its side here with sepsis-3. But I hope it has engaged clinicians, coders and statisticians who can perform a fair and thorough clinical review, and analysis of the true costs.

The report is planned for 2025 publication.

References

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