How are Sepsis Denials Impacting your Star Based Revenue Performance?
Quality of care and performance based reimbursement requires precise documentation details for disease specificity, acuity, and treatment provided.
Sepsis is a high resource consumption medical condition that should be identified specifically in terms of type of sepsis, clinical findings, and or risk factors.
Sepsis should be documented with the NYS-DOH Sepsis Identification/Reporting requirements always in mind.
External third party and payer audits for “Clinical Validation of Sepsis” are using Sepsis 3 or other criteria to deny payment for sepsis.
The sepsis denials are resulting in negative impact on sepsis reportable data, MS/APR DRG reimbursement, other bonus revenue associated “Star Rating” for quality of care performance measures.
These denials for Sepsis have a primary and secondary impact on Revenue Cycle.
Hospital Star Rating$
The Sepsis-Star rating connection is worth millions!
- One Star Hospital status?
- Sepsis “Clinical Validation Denials”?
Readmission Mortality and Sepsis Denials are linked to Annual Performance Based Incentive Star Ratings Reimbursement.
Sepsis Denials Impact on the Hospital Star Ratings
Nationwide, the most common hospital rating was three stars.
In New York State
Of 151 hospitals graded statewide, 48 hospitals got a one-star grade.
The only hospital to attain a five-star rating was Hospital for Special Surgery in New York City.
Two Targeted Solutions
Sepsis Reimbursement Dispute Resolution Determinations:
Timely and Impartial Determination Review Services to Resolve Provider & Payer Clinical Sepsis DRG Payment Disputes.
DSRIP Concurrent and Retrospective Focused Reviews:
Quarterly PQI/PDI diagnosis Re-Evaluation support by Coding, and Physician CDI Experts. Targeted Medical Record Review Services for All Hospital Acute DSRIP Admissions.
Our Indusrty Leading DRG and Clinical Documentation Experts
Ms. Gardner-Brown is a Subject Matter Expert, Speaker, DRG Dispute Resolution Examiner and experienced Auditor for the acute and outpatient care settings. She is also an AHIMA approved ICD-10- CM/PCS trainer that has developed and presented educational material on several ICD-10-CM/PCS and CDI topics.
Ms. Gardner-Brown has more than 30 years’ experience in both hospital and professional coding, clinical documentation improvement, denials management, and revenue cycle integrity.
Deborah Gardner-Brown is the founder of Sepsis Integrity Review Services, and Principal Consultant for Reimbursement Review Associates Inc.
Dr. Keith stokes is a board-certified physician with a diverse career that includes experience as a clinic medical director, hospital chief of staff, and hospitalist medical director, consultant and physician advisor.
Dr. Stokes has served as a consultant for numerous hospitals, primarily focused in the areas of utilization management and clinical documentation improvement.
Dr. Stokes acquired DocuComp LLC in April of 2017 and is currently a certified Physician Advisor and a Clinical Documentation Improvement and Integrity instructor.