New SmartPhrase for sepsis documentation starts March 27

See SBAR for details

Situation:

This improvement started with four needs:

1. Improve documentation for patients with sepsis;
2. Decrease the number of email inquiries from Clinical Documentation Improvement (CDI) to providers;
3. Clearly and correctly document the patient’s condition and
4. Get reimbursed for the care provided and expenses incurred.

To do this, we created a provider SmartPhrase.

Background:

Sepsis diagnoses are the largest denied diagnoses by both private insurance and Medicare. Between August 2022 and January 2024, there have been 399 cases submitted, of which Salem Health has been denied $3,735,638 in reimbursement. Of that total, $161,387 has been recovered. Our success on a denied claim is less than 20%. Of our top 10 denied codes, sepsis diagnoses are four out the 10. The primary reason for these denials is the wording used in writing diagnoses.

Assessment

While collaborating with the CDI team and reviewing the highest denied claims, a group of CDI members, intensivists and hospitalists problem-solved how to better communicate the diagnosis in provider notes. The goal was to make an easy “smart phrase” for providers to use that captures most sepsis patients in a format that improves the four challenges mentioned above.

Recommendation

A SmartPhrase for sepsis goes live on Wednesday, March 27.It can be found by two headings: SepsisAProviderNote or Hospsepsis. Either of these will pull up the following smart phrase (see screenshot below).

There are three simple sections:

1. Sepsis: On admission, pick present or not present.
2. Due to: Choose the most appropriate source of infection, if known, or choose *** to enter text.
3. With sepsis-related organ dysfunction: Choose the system affected, not the lab/imaging result or choose *** to enter text.

Here is an example of a finished sentence:

Sepsis, present on admission, due to aspiration pneumonia with sepsis-related organ dysfunction of acute kidney injury.

And that’s it! This should make your work life easier and should decrease queries by CDI staff.

After we start this new SmartPhrase, we’ll assess data to see if queries improve.

Questions?

Contact gwen.schneider@salemhealth.org, danielle.britt@salemhealth.org or seunghyo.hong@salemhealth.org.