“muddy waters” as mud_ the...7 reimbursement issues • use singer et al. paper to your...
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“Muddy Waters”
Chadrick Sims BSN, RN, SCRN, EMT
Sepsis and Rescue Coordinator
UT Medical Center
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Sepsis Definitions
PSI #13 (Patient Safety Indicator) Post Surgical Sepsis
CMS SEP-1 Sepsis Core Measure
Tips
The Plan
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Sepsis 2
vs.
Sepsis 3
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Definition
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Coding / Billing
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• Problem: Recognized Sepsis 3 greatly raised
clinical threshold for making diagnosis of sepsis
– Immediately reviewed 20 UTMC sepsis MS-DRG cases:
• 50% would not make the new Sepsis 3 cut
– Not a problem for those that went to the ICU
– HUGE problem for those that went to the floor
• Meaning = HUGE recovery auditor opportunity if Sepsis 3
definition employed in clinical validation reviews
Reimbursement Issues
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Reimbursement Issues
• Use Singer et al. paper to your advantage!– The Third International Consensus Definitions for Sepsis
and Septic Shock, Journal of the American Medical Association, Feb 2016, vol. 315, no. 8, pgs 801-810
• "Neither qSOFA nor SOFA is intended to be a stand-alone definition of sepsis.”– This line should be quoted in every Sepsis 3 appeal
letter your organization sends!
• Appeal letters NOT written for the RA/Payer!
• Appeal letters are ultimately written for the ALJ or
independent review you will eventually reach
– If we keep pounding the independents with
idea qSOFA and SOFA not the only answer .
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• Released 2/13/2019: Guidelines for Achieving a Compliant Query Practice (2019 Update) written by both AHIMA and ACDIS– Available at ACDIS & AHIMA websites, no membership needed
– Well worth the read!• “While organizations, payers, and other entities may
establish guidelines for clinical indicators for a diagnosis, providers make the final determination as to what clinical indicators define a diagnosis.”
– Translation: parties not directly involved in the care
of the patient should not be determining what
disease processes that patient may or may not have
– Now in every UTMC MS-DRG validation appeal
Reimbursement Issues
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Statistics
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Adoption of Sepsis -3
Sepsis -3
Research
PSI #13
SEP-1
Performance
Improvement
Internal
External
Grants
Peer Comparison
Internal MonitoringShould Improve
Denominator
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Trending Statistics
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
UTMC Mortality - O/E RatioSepsis without Shock vs Severe/Shock
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
UTMC GLOS - O/E RatioSepsis without Shock vs Severe/Shock
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
UTMC Complications - O/E RatioSepsis without Shock vs Severe/Shock
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
UTMC Readmissions - O/E RatioSepsis without Shock vs Severe/Shock
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Can you change your sepsis program in six months? One
year?
The Plan:
1. What will trigger change?
2. Communications
3. Key responsibilities
4. Timeline
• policies, protocols, educational materials
• electronic / computer / software
• staff education (providers, nursing)
• coding / billing
Contingency Plans
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PSI #13
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PSI 90
Patient Safety Indicators (PSI’s) are a set of 10 measures that screen for adverse events that patients experience as a result of exposure to the health care system
PSI’s are used in all of the following:
Pay-for-Performance / Value-based Purchasing
Hospital-acquired Conditions penalty program
Hospital Compare
CMS Star Ratings
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PSI #13
PSI #13 - “Postoperative Sepsis” – elective surgical discharges > 18 years old with secondary diagnosis of sepsis; excludes the following:
Sepsis /infection present on admission
Pregnancy, childbirth, puerperium
PSI #13 is the second most-heavily weighted PSI-90 measure at 25.5% of the composite score
PSI #13 at UTMCK is 16% above the national average (below = better)
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We Had A Problem
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Understanding PSI #13
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Charting
Differentiate between:
SIRS d/t surgical procedure
vs.
SIRS d/t infection
A Victory!
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• Immunocompromised patients
• Immobile patients
• Those that are at high risk for post surgical pneumonia
• Aspiration pneumonia
Source of Infection – PSI #13
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Follow-Up
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Follow-Up
All follow-up letters have a description of PSI #13 at the bottom
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Our Trends
PSI#13 Rate per 1000
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CMS SEP-1
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Hospital Compare
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Hospital Compare
• Peers• Limitations• Past• It’s (not) accurate• Not a “Big Four”
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Making Metrics
Triage Time to Antibiotic Administration
Provider Order to Antibiotic AdministrationTriage to Treatment
Decision to Treat
3 Hour Goal
1 Hour Goal – Nurse Driven“Flow”
Provider Driven
Sepsis Order Set (to be completed within 1 hour of order or 3 hours / triage):
• Blood cultures x2• STAT lactic acid with automatic 3 hour F/U• Antibiotics• 1 liter NS / RL
Give fluids (use order set), adjust to patient responseUse pressor drip EARLYChart response (use matrix)
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OH GOD, IT’S A CLASSIC….
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Provider Feedback
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Monitoring
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RN Performance
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RN Performance Card
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Tips
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Know Your Volumes…….
Tips
4.37%
6.05%
6.91%
7.85%
8.64%
9.29%
11.00%11.37% 11.41%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
2010 2011 2012 2013 2014 2015 2016 2017 2018
% o
f T
ota
l
Year
% of Total Adult Discharges with Sepsis as Primary Diagnosis
% of Total Pts w Sepsis as Primary Dx Trend
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Raw vs O:E……
Tips
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Tips
Raw vs O:E……
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Charting Sepsis……
Tips
• Difficult IV’s• Patient refusal (for anything)• Combative patients• Triage not in triage (stroke, AMI)• Fluids prior to arrival• Medications prior to arrival• Comfort care / Hospice
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Know Your Side Effects…….
Tips
• C-difficile rates• Antibiotic administration rates• Reaction rates• Dialysis trips• Staffing• Equipment availability
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Get Involved…….
Tips
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Chad Sims
Sepsis and Rescue Coordinator
“Sepsis Care Coordinator UTMC” – PerfectServe®
Office: 865-305-6497 Cell: 865-705-9996
“Network Friendly”
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Adding Email Templates