The Association Between Sepsis Coding and Payment to U.S. Hospitals.

Area of Science:

• Healthcare economics
• Infectious disease epidemiology
• Health services research

Background:

• Sepsis diagnosis and classification are critical for patient care and resource allocation.
• The Sepsis-3 definition aims to standardize sepsis identification based on organ dysfunction.
• Understanding the concordance of clinical practice with Sepsis-3 criteria is essential for accurate healthcare assessment.

Purpose of the Study:

• To determine the prevalence of Sepsis-3 concordant and discordant sepsis hospitalizations within Traditional Medicare.
• To evaluate the financial impact of Sepsis-3 discordant hospitalizations on Medicare spending.
• To identify common alternative diagnoses associated with Sepsis-3 discordant sepsis cases.

Main Methods:

• A retrospective observational study utilizing a 100% sample of Traditional Medicare inpatient claims from 2016 to 2022.
• Inclusion of acute care hospitals under the Inpatient Prospective Payment System, excluding specific regions.
• Classification of sepsis hospitalizations (identified by DRGs 870-872) as Sepsis-3 concordant or discordant based on the presence of acute organ dysfunction diagnosis codes.

Main Results:

• Approximately 22.6% of 4.2 million sepsis hospitalizations lacked acute organ dysfunction codes, classifying them as Sepsis-3 discordant.
• Common alternative diagnoses for discordant hospitalizations included pneumonia, urinary tract infections, and skin infections.
• Sepsis-3 discordant hospitalizations had significantly lower 30-day mortality (7.7%) compared to concordant ones (33.4%).
• Discordant hospitalizations incurred an average of $839 more per case than simple infections, totaling an estimated $114 million in excess annual payments.

Conclusions:

• A substantial proportion of inpatient sepsis hospitalizations in Traditional Medicare may not align with Sepsis-3 criteria.
• This discordance contributes significantly to increased healthcare expenditures.
• Recommendations include aligning ICD-10 coding guidelines with clinical definitions to improve accuracy and potentially reduce costs.