Confidentiality, Privacy and Security

Insurance denial for sepsis

  • 1.  Insurance denial for sepsis

    Posted 09-22-2020 17:01
    Hey everyone,

    Please forgive me for this lengthy post.  And if I'm not posting this to the correct community.

    I'm an inpatient coder at an acute inpatient hospital.  We're currently having an issue with a certain insurance company with regards to claims with the sepsis coded.  They state that the patient didn't meet the clinical criteria for the sepsis (based on their own criteria for sepsis, not CMS' criteria).  The medical director at our facility reviews the record when the denials are received and normally agree's with the insurance company.

    The treating physicians on the case are documenting in the legal medical record that the patient has sepsis and is being treated for the sepsis.  we are coding the sepsis based off of the physicians documentation that the condition exits.  We have tried to appeal with the insurance company with the coding guidelines that state "Code assignment and Clinical Criteria: The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists.  The provider's statement that the patient has a particular condition is sufficient.  Code assignment is not based on the clinical criteria used by the provider to establish the diagnosis."

    Our facility (no one who is AHIMA certified) is wanting us (the coders) to remove the diagnosis of sepsis from our coding without having any documentation in the legal medical record to justify the removal of the code.

    Our previous HIM director (who was a RHIA) has already  explained to the denial coordinator that the coder cannot remove the diagnosis code just because the insurance company doesn't want it.  Her suggestion was to have the medical director or the attending physician do an addendum to the record to say that the sepsis was ruled out.  We have no problem removing the diagnosis if there's documentation to support the removal.

    Is it ethical (or even legal) for us to remove a code without the corresponding documentation in the medical record?

    Has anyone else had this type of situation happen to them?  What do other facilities do when the insurance company is refusing to pay for a diagnosis that it clearly documented in the record?  Any insight would be greatly appreciated.  Thank you in advance for you help and insight!

    Dawn K.
    CCS Coder

  • 2.  RE: Insurance denial for sepsis

    Posted 09-23-2020 14:51
    It is not ethical to remove a code without proper documentation in the medical record.  See below.

    Code assignment and Clinical Criteria
    The assignment of a diagnosis code is based on the provider's diagnostic
    statement that the condition exists. The provider's statement that the patient
    has a particular condition is sufficient. Code assignment is not based on clinical
    criteria used by the provider to establish the diagnosis.

    Susan Borden
    Director Health Information Management and Medical Staff Services
    Cullman Regional Medical Center

  • 3.  RE: Insurance denial for sepsis

    Posted 09-24-2020 09:52
    Hi Susan,
    While I agree with your statement, our facility is getting audited by the insurance companies and if the changes are not made and the codes are not removed, ie. which changes the DRG, and then we need to submit a revised claim, the insurance company is denying the entire patient stay.  (Which our small rural facility cannot afford to lose.)  

    I would be very interested to see how others are dealing with this issue.  We are in the process of implementing a plan, at the very least, puts a note within the patients account stating why these changes were made.  

    Sue Nathe, RHIT

    HIM Manager

    Tri County Health Care 

    415 Jefferson Street N · Wadena, MN 56482 

    D: 218-632-8141





    Confidentiality Notice: This e-mail and any attachment(s) may contain confidential information that is legally privileged. This information is intended only for the use of the addressee named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation. If you are not the intended recipient, you are hereby notified any other use, disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this transmission in error, please notify the sender immediately, reply to this transmission, or contact the Tri-County Health Care Privacy officer at (218) 631-7504 and delete these documents.

  • 4.  RE: Insurance denial for sepsis

    Posted 09-24-2020 10:10

    We added to our coding policy a paragraph that once a claim is denied due to the carrier's criteria (check your contract with the insurance carrier), we will follow the carrier's policy and change coding. We require the coder to add a comment in B/AR if they alter coding assignment and reason for change. Also in the policy it states insurance carrier contracts and criteria will be followed (as well as state requirements).



    Deborah Gagné, BS, RHIA, CHPS

    HIM Director, Privacy Officer

    Garrett Regional Medical Center

    251 North Fourth Street

    Oakland, MD 21551

    Ph:   301-533-4120

    F:      301-533-4147






  • 5.  RE: Insurance denial for sepsis

    Posted 10-22-2020 16:32
    HI, we are also a small rural facility and if the insurance company denies and specifically gives a reason vs. "not medically necessary" we are changing the code and documenting it was based on insurance recommendation.

    Ilene Estabrook, BA, RHIT, CHAM
    Health Information Manager, Privacy and Compliance

    Ilene Estabrook
    Him Manager

  • 6.  RE: Insurance denial for sepsis

    Posted 10-23-2020 09:38
    I bet I can guess the insurance company.  Almost all of our issues originate with United Healthcare - copies (multiple), coding, denials, EMR access, etc.  I almost forget to ask which insurance company any more...

    Nancy Davis, MS, RHIA, CHPS
    Director of Compliance & Safety
    Door County Medical Center