(1601) Characteristics of Patients With Payment Denials for Sepsis

Introduction: US insurance reimbursement is based on ICD-10 (International Classification of Diseases Version 10) coding. ICD-10 codes were released by the WHO (World Health Organization) in 1994. A newer ICD-11 version was endorsed in 2019 by the WHO. Both ICD versions utilize Sepsis-2 definitions which include mild and severe sepsis along with septic shock, unlike Sepsis-3 definitions (2016) which distinguish only between sepsis and septic shock, eliminating severe sepsis. Sepsis-3 criteria will continue to differ with ICD-11 codes. The aim of the project was to evaluate clinical characteristics of patients coded for sepsis for which insurers disputed payment and understand which criteria the insurer used for the case disputes.

Methods: Retrospective chart review (HFH IRB 16534, Dissident Study) of all dispute cases for sepsis encountered at a five-hospital system in Southeast Michigan for disputes from June 2020-February 2024.

Results: There were 1111 dispute cases. Mean patient age was 63.8 (SD 21.3, Median 68.3; 17.8-103.1 ) years. The patient population was 48% male . SIRS (SIRS 0-1) criteria were not present for 71 (6.4%) patients while present (SIRS 2-4) in 1040 (93.6%). qSOFA 0-1 was noted for 734 (66.7%) patients and qSOFA 2-3 was noted in 366 (32.9%) patients, (missing N=11). SOFA score criteria < 2 was noted for 482 (43.3%) patients and ≥2 for 618 (55.6%) patients. Lactate/lactic acid of < 2.1 mmol/ L was recorded in 521 (46.9%) while lactate ≥2.1 was recorded in 508 (45.7%) patients, 82 (7.2%) patients had no measurements. The most prevalent organ impairments were in the respiratory system N=445 (40.1%), cardiovascular system N=416 (37.4%), the renal system N=355 (32%) and central nervous system N=238 (21.4%). Using ICD-10 criteria 71 (6.4%) had an infection, 268 (24.1%) were septic, 672 (60.5 %) had severe sepsis and 100 (9.0 %) had septic shock. Insurers disputed the cases based on Sepsis-3 definitions 974 times (87.7 %). Dispute average was $5,017 (SD6,335) while dispute median was $3,491 ($7-$77,486) resulting in a total dispute volume of $5,569,514.

Conclusions: Despite correct coding based on ICD-10 criteria, insurers in Southeast Michigan dispute sepsis based on non-ICD-10 codes that conform to Sepsis-3 definitions, contributing to a significant financial burden for health care systems.