Sepsis-2, sepsis-3, or sepsis-2.5? Varying definitions lead to denials

By Brian Murphy

Sepsis is back in the news. I doubt many in the CDI and coding communities are surprised.

Sepsis remains at the most frequently posed query among CDI professionals. The most recent ACDIS CDI Week Industry Overview Survey had sepsis topping the list, followed by respiratory failure and malnutrition.

Sepsis a difficult condition to diagnose, frequently requiring a team of specialists. It requires a lot of resources to treat.

And it’s extraordinarily deadly. In a typical year at least 1.7 million adults in America develop sepsis, 350,000 of which either die during hospitalization or are discharged to hospice.

That makes accurate diagnosis, documentation, and coding incredibly important.

The CDC last week released “Hospital Sepsis Program Core Elements” to help combat this scourge. It outlines a plan and offers up a detailed checklist for stewardship, accountability, action, tracking, reporting, and education of the diagnosis.

Bullet 42 of the checklist is a mandate for CDI review: “Our hospital completes near real-time chart reviews for the purpose of clinician feedback and education.”

Always a difficult condition to diagnose and treat, the confusion around sepsis has intensified due to varying definitions in the clinical literature.

For years most hospitals used sepsis-2 criteria. Many still do. Per ACDIS (see paper below, requires membership), 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.

This ongoing debate and clinical murkiness has unsurprisingly led to insurance denials.

Hospitals are encouraged to develop consistent clinical criteria to apply to contested conditions. In an ideal world payers and hospitals would see eye-to-eye on these, leaving little room for denial.

In reality that is not the case. Payers will use whatever definition is at hand to deny sepsis and downgrade a DRG.

My friend and Off the Record guest Howard Rodenberg this week tipped me off to a third definition, sepsis 2.5, published this week. Its goal is to reconcile this divide by bringing a payer to the table with a hospital to, “develop a community-based, literature-supported consensus definition for sepsis characterized by the presence of clinical illness, a source of infection, and evidence of organ dysfunction.” You can read the paper below.

I’m not a clinician nor do I play one on TV, but in my non-clinical opinion the CDC’s definition (“the body’s extreme response to an infection”) in its new core elements program seems to cleave closer to sepsis-3. But it’s not definitive.

So, sepsis-2, sepsis-3, or a hybrid/sepsis-2.5? What does your organization use, and what are your thoughts? I welcome any commentary on this.


ACDIS, “Where Are We Now With Sepsis?

CDC, “Hospital Sepsis Program Core Elements”:

Critical Care Explorations, “Sepsis-2.5: “Resolving Conflicts Between Payers and Providers”:

Medium, “The Sepsis Confusion: Sepsis-2 or Sepsis-3?”:

Related News & Insights

Solutions Spotlight: OIG Toolkit a Valuable Blueprint for Risk Adjustment Coding Compliance

By Brian Murphy The OIG Toolkit To Help Decrease Improper Payments in Medicare Advantage Through the Identification…

Read More read more

Five Emerging Mid-Revenue Cycle Roles

By Brian Murphy New job functions will be needed to meet the changing nature of healthcare delivery…

Read More read more