Menu
Sepsis remains one of the most frequently denied diagnoses for hospitals in the United States by payers. A significant number of these sepsis denials occur when patients meet only Sepsis-2 SIRS criteria, which continues to be used by many hospitals despite the adoption of the Sepsis-3 definition in 2017. In cases where the Sepsis-3 criteria are not met, such denials would be considered appropriate.
In recent years, however, certain payers claim to use the Sepsis-3 definition as justification to deny sepsis but base their denial on adaptations not supported by the official Sepsis-3 criteria.
We requested Dr. Marvyn Singer, lead author of the Sepsis-3 definition, to provide his perspective regarding specific rationales used by payers to deny the diagnosis of sepsis and assess whether these rationales align with Sepsis-3 guidelines.
Below are the common payer denial rationales found in DRG downgrade letters, along with Dr. Singer’s response:
| Payer Sepsis Denial Rationale | Dr. Singer's Response |
|---|---|
| “There was no documentation found within the medical record to support an acute change in baseline SOFA score of 2 or more points after an initial bolus/challenge (unless contraindicated) that is related to infection and not explained by other causes.” | This is incorrect. “after an initial bolus/challenge” only applies to the diagnosis of septic shock, not sepsis. |
| “SOFA values must be present after an initial fluid challenge to achieve a minimum of 30 mL/kg of crystalloids (e.g., normal saline, Lactate Ringer’s) (Surviving Sepsis 2021, Recommendation 5)” | This is incorrect. No specific volume requirement was mentioned in Sepsis-3. 30 ml/kg was an SSC recommendation (notably based on no good evidence!) |
| “Direct organ dysfunction is not a dysregulation response and therefore is not counted in the SOFA score.” “Example: A low PaO2/FIO2 from acute (pneumonia) or chronic (COPD, etc.) lung disease is direct organ dysfunction and not counted towards meeting SOFA criteria.” | This is incorrect. Direct organ dysfunction following, for example, pneumonia, urosepsis or meningitis are consequent to an excessive host response triggered by the infection – both local and (usually) systemic. |
| “[Payer] requires the medical record meet the following guideline for Sepsis: Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. [Payer] recognizes clinical criteria that are made up of three areas: 1) Documented infection, presumed or confirmed, AND 2) Documentation by the clinician that there is life threatening, acute organ dysfunction/failure present due to a dysregulated septic response to infection. Organ dysfunction/failure includes, but not limited to: --AKI using KDIGO --Acute Hypoxemia P/F less than 300 --Hyperbilirubinemia total bilirubin greater than 4 mg/dL --Thrombocytopenia less than 100K --Paralytic ileus absent bowel sounds --Critical illness myopathy or neuropathy --Type 2 myocardial infarction --Encephalopathy sepsis derived equals metabolic type --Coagulopathy INR greater than 1.5 --Hypotension SBP less than 90 mm Hg or fallen by greater than 40 from baseline, MAP less than 70 mm Hg, AND 3) Appropriate pharmacotherapy is ordered/given based on the causative organism | This is incorrect. 1) Agree, must have presumed or confirmed infection. 2) This is incorrect. … can score 1 point in 2 organ systems and that qualifies as sepsis 3) This is incorrect. Many viral diseases have no treatment. |
To hear Dr. Marvyn Singer, lead author of Sepsis-3, debunk these payer denial issues, explain the evolution of Sepsis-2 SIRS to Sepsis-3, along with the new SOFA-2 score, watch the webinar replay. To access this special session and all our webinar replays, purchase the 2026 CDI Pocket Guide® or Unbound Edition. Or you can purchase this webinar on-demand for $29.
Existing CDI Pocket Guide® customers can log in to their CDI+ portal to view Dr. Singer's session along with the complete webinar library.
(c) Copyright 2025 Pinson & Tang LLC
Contact Customer Service at (713) 292-9412 or [email protected]
