Top Tips: Succeeding with Sepsis (SEP-1)

Speaking with abstractors about sepsis will bring about a multitude of reactions. Eye-rolling, words of disgust, and even complete dismissal of the topic. In today’s Medisolv blog, we are going to talk about some of the stumbling blocks the sepsis algorithm and abstraction of Sepsis can cause. 

First, a bit of education. The official name is Severe Sepsis and Septic Shock: Management Bundle (Composite Measure) with a measure set ID of SEP-1. SEP-1 is required under the CMS Inpatient Quality Reporting (IQR) program. The Joint Commission does not accept sepsis nor has any abstracted measure requirements related to sepsis.

There are many general data elements (First Name, Race, Sex, etc.) to support the measure, but even more specific data elements to calculate the measure such as blood culture, lactate draw, and crystalloid fluid administration. The sheer number of data elements can make this a difficult measure for abstractors.

How is the SEP-1 Initial Patient Population (IPP) defined?

To meet criteria for sepsis, a patient must be admitted to the hospital as an inpatient. An ICD-10-CM principal or other diagnosis code for sepsis diagnosis must be assigned. In addition, none of these codes should equal U07.1 (COVID-19). The patient must be greater than or equal to 18 years of age and have had a length of stay less than or equal to 120 days.

Tips for Succeeding with Sepsis

Measure Education

I can’t stress this one enough as education is key to succeeding in the ever-changing, ever-evolving sepsis world. It is important to familiarize yourself with the measure. This can be accomplished by checking the CMS specifications manual. It is important to understand the IPP, notes for abstractions, and sampling related to this measure. In addition, we encourage our clients to attend webinars given by CMS that review the specifications related to sepsis. You can also sign up for the CMS IQR Listserv for updates and announcements related to specification updates as well as release notes.

Diagnosis Codes

CMS is the measure steward and is responsible for the sepsis specification. The IPP, general, and specific data elements associated with sepsis, sampling, and algorithm logic are all determined by CMS. Medical Record coding for sepsis can either be based upon the principal or other diagnosis code where some other measure sets only focus on the primary diagnosis code as the requirement. Please be mindful that a sepsis diagnosis code can be either the primary or secondary diagnosis code. If a code of U07.1 is identified, this will cause the case to be excluded from the population. To be clear, it is not counted in the IPP.

Data Element Names

Blood Culture Collection, Broad Spectrum Antibiotic Administration, and Initial Lactate Level Collection – it is important for the abstractor to consider the specified timeframe in determining a Yes or No allowable value. There are no Critical Edits for these data elements per the CMS Edits document. The algorithm does not consider an incorrect response to Blood Culture Collection, Broad Spectrum Antibiotic Administration, and Initial Lactate Level Collection by putting in any algorithm checks for these data elements. In the notes for abstraction, the abstractor should be aware that the broad spectrum or other antibiotic administration time is within or not within 24 hours before the Severe Sepsis Presentation time and provides guidance for the data collection timeframes that must be considered prior to selecting Yes or No. 

• Per the Notes for Abstraction, if the Broad Spectrum or Other Antibiotic Administration Time is not within the 24 hours before the Severe Sepsis Presentation Time, the specified time frame is:
  • 24 hours before the Severe Sepsis Presentation Date and Time through three hours following the Severe Sepsis Presentation Date and Time.

• Per the Notes for Abstraction, if the Broad Spectrum or Other Antibiotic Administration Time is within the 24 hours before the Severe Sepsis Presentation Time, the specified time frame is:
  • 24 hours before the Broad Spectrum or Other Antibiotic Administration Time through three hours following the Severe Sepsis Presentation Date and Time.

Crystalloid Fluid AdministRation and Persistent Hypotension

Often abstractors are not aware that Crystalloid Fluid Administration and Persistent Hypotension are validated at two points in the Severe Sepsis algorithm. It is important to understand the flow of the algorithm and how this impacts the measure category assignment.

Measure Category Assignments

For Severe Sepsis, if one data element fails, such as Blood Culture Collection, Broad Spectrum Antibiotic Administration, and Initial Lactate Level Collection, the entire measure fails.

Severe Sepsis vs. Sepsis

Severe Sepsis vs Sepsis definitions. We hear from abstractors that view Severe Sepsis as being the same as Sepsis. This is not true. Sepsis happens if there is a bacterial, viral, or fungal infection. The body’s immune system responds by causing a high heart rate, fever, or tachypnea (fast breathing). Severe Sepsis develops when the infection causes organ damage. Remember to understand the measure definition and apply the logic in the specifications during abstraction.

Transfer In from another acute care facility

The denominator statement for SEP-1 reads as follows: Inpatients age 18 and over with an ICD-10-CM principal or other diagnosis code of sepsis, severe sepsis, or septic shock and not equal to U07.1 (COVID-19). Sound familiar? For those patients that are transferred into your acute care facility, they may still qualify for the measure. A transfer in from another acute care facility does not exclude the patient from the initial patient population. Once the algorithm logic engine in our ENCOR for Hospital Abstracted Measures application applies that logic to a case, if the patient was transferred into another acute care facility, this is considered an exclusion from the denominator. We see confusion that this should be excluded from the IPP. This is incorrect. The case still qualifies for the IPP based upon the sepsis IPP. It must be counted in the IPP count per CMS specifications.

Mistakes Viewing Reports

Common mistakes viewing reports in Medisolv’s Sepsis Bundle Breakdown vs Sepsis Bundle Reports. For some this may not apply but the overall theme will. Use the reports that are available to you regardless of the vendor. There has been much discussion and thought put into the reports to serve the greater good. For Medisolv clients, the Sepsis Bundle Report is based upon the Sepsis algorithm also known as the ‘top grid.’ For the Sepsis Bundle Breakdown Report, it is based upon the sepsis data elements. 

Medisolv offers a wide range of products and solutions to meet all your quality reporting needs. Some recent posts have focused on Sepsis including How to Prepare for CMS’s New Sepsis Requirements. The blog discussed CMS’s move in the proposed rule to add SEP-1 to the Hospital Value Based Purchasing Quality Reporting Program.

Please let us know if you have any questions or need more information concerning Medisolv and how we can assist you.