Sepsis: A Common, Costly Challenge for Health Plans
Kyle Busch made his name in a sport built on speed, risk and split-second decisions. But it was sepsis — one of the deadliest and costliest conditions in the U.S. — that ultimately took his life earlier this year.
After childbirth, sepsis is the leading cause of hospitalization in the United States. It is also the most expensive, with annual costs exceeding $52 billion — more than 14% of all hospital costs. This is due to its complexity, high mortality and the need for intensive, often prolonged care.
For health plan sponsors, the issue is not just what sepsis costs, but when and how it developed. About 15% of sepsis cases start in the hospital. That may not sound like much, but hospital-acquired sepsis often leads to longer stays, generates five times the cost and is twice as deadly. The risk is even greater in intensive care, where more than 45% of cases develop during the stay.
A thorough claim audit can help determine if sepsis was a hospital-acquired condition. Answering that question matters for plans that want to ensure reimbursement accurately reflects the care delivered and the plan’s responsibility.
What Causes Sepsis, and Who’s at Risk?
Sepsis occurs when the body’s ability to fight infection turns on its own organs and systems and can lead to a dramatic drop in blood pressure known as septic shock. When the damage is severe, it can lead to death.
Any type of infection can lead to sepsis. This includes bacterial, viral or fungal infections. Those that more commonly cause sepsis include infections of:
- Lungs, such as pneumonia
- Kidney, bladder and other parts of the urinary system
- Digestive system
- Bloodstream
- Catheter sites
- Wounds or burns
Most people who develop sepsis have at least one existing medical condition or a weakened immune system. Factors that increase the risk of sepsis include age (infants or those over 65), chronic diseases, admission to intensive care or longer hospital stays, and devices that go into the body (i.e., catheters in the vein, breathing tubes).
As sepsis worsens, vital organs — such as kidneys, heart and brain — do not get as much blood as they should. Sepsis may cause atypical blood clotting, which can damage or destroy tissues.
Early treatment of sepsis improves chances for survival. Healthcare providers may first notice symptoms such as fever, increased heart rate, low blood pressure or trouble breathing. Laboratory tests are performed to identify the germ causing the infection that led to sepsis. Treatment includes antibiotics, maintaining blood flow to organs and in some cases surgery to remove tissue damaged by the infection.
The Complexity and Pitfalls of Sepsis Coding
The proper diagnosis coding of sepsis is complex due to the numerous codes to select from, evolving guidelines/updates, overlapping terminology and strict medical record documentation requirements often lacking and needed by medical practitioners.
Correct coding of sepsis according to specific, detailed guidelines impacts Medicare Severity Diagnosis Related Groups assignment and reimbursement. Billing pitfalls include:
- Overcoding: Assigning sepsis without confirming infection or organ dysfunction.
- Undercoding: Using systemic inflammatory response syndrome or bacteremia without “sepsis” in the medical record documentation.
- Confusing terms: “Urosepsis” may mean urinary tract infection or sepsis and must be clarified with the practitioner.
- Missing secondary codes: Failing to document and code organ dysfunctions.
Audit Example: How We Reduce the Cost of Sepsis
ClaimDOC’s audit team routinely audits hospital inpatient claims with sepsis diagnoses to ensure accurate pricing.
While the case below is designated as present on admission, it still demonstrates long hospitalization and high cost of care. A middle-aged male was admitted to a California hospital for 24 days. His principal diagnosis was A41.9 sepsis, unspecified organism and other diagnosis of R65.21 severe sepsis with septic shock present on admission. The patient had multiple other diagnoses reported, including heart failure, respiratory failure and pneumonia.
- Total hospital billed charge: $1,185,528.21
- Hospital-reported cost: $238,057.63.
- ClaimDOC pricing: $248,090.59
- Our price was based on the cost of care received plus 20%, with carveouts for unbundled services. Review of medical records and the itemized bill identified unbundled services in Rev Codes 250, 258, 300, 410, 450 and 730.
- ClaimDOC cost reduction: $937,437.62 (79%)
Sepsis claims demand close attention because clinical severity, coding specificity and cost are tightly connected. A disciplined audit gives plan sponsors a defensible way to verify that reimbursement reflects the care delivered — not merely the amount charged.