Chart Check Up
Leveraging clinical perspectives for the middle revenue cycle – insights that drive impact. Offering support to keep current on clinical knowledge, coding updates, and industry trends.
Chart Check Up
Confronting the Phoenix Criteria
Episode Outline:
• Phoenix Criteria overview
• Challenges identified with Phoenix Criteria as stand-alone Sepsis diagnostic tool
• The payer landscape: Reimbursements & denials
• Considerations for CDI professionals conducting chart reviews
Email info@acuityhealthcare.com with your questions or suggested topics for future episodes.
Welcome to Chart Checkup clinical perspectives for the middle revenue cycle. This podcast delivers insights that drive impact in healthcare information management. Stay current on clinical knowledge, coding updates and industry trends through expert interviews and conversations with Acuity's own physician, cdi and coding leaders. Hello, I'm your host, bill Hancock. I'm the education analyst for Acuity. I'm happy to welcome Acuity's vice president of CDI, mary McGrady, as our first guest speaker and CDI subject matter expert. It's wonderful to have you as a guest and thank you for being here. Mary, will you tell us about what you do at Acuity and your experience as a CDI leader?
Speaker 2:Sure, hi, bill. I have been in CDI for upwards of over 15 years. Came to Acuity just over five years ago, where I am the VP over our CDI team. Our CDI team works with a lot of hospitals and we affectionately call ourselves CDI query writers. Prior to coming to Acuity, I worked in an academic medical center in New York City as a director of a CDI program, so it's sort of my passion. Thanks for having me.
Speaker 1:It's our pleasure, thank you. I'm also happy to introduce our second guest, which is another ACUITY CDI subject matter expert, lena Belcher, as our second guest speaker. It's wonderful to have you. Thank you for being here, and can you, lana, can you introduce yourself and tell us a little bit about your CDI experience?
Speaker 3:Absolutely. Thank you for having me too, Bill. I have been in the CDI world a little over 10 years and I've big portion of the clinical content and educational material that we provide to our clients or clinicians and CDI encoding in a variety of multimedia formats, and so the educational material that we produce is kept up to date clinically and based on current guidelines and practices within CDI encoding to make sure that it's relevant and stays current for our client.
Speaker 1:Awesome. I really appreciate it, and I think that the interesting topic for today that we've lined up is something that you came up with, lena.
Speaker 3:That's right. I am super excited to speak with you guys today because I want to discuss my current favorite topic of pediatric sepsis and the launch of the Defining Sepsis Phoenix Criteria Scoring System, which was published back in January of 2024. The system was developed by the Society of Critical Care Medicine, sccm, and this is the same group that who published the sepsis one through sepsis three, and so recent studies had shown about 50 million people are affected by sepsis across the world and around half of those are children younger than 19. So the SCCM sought out to define the diagnosis of pediatric sepsis that's going to be well supported by pediatric-specific evidence rather than focusing on adult-specific evidence. So in doing so, they developed a new definition of what pediatric sepsis is and the criteria were created for the Phoenix scoring system, which includes a four organ system model and it helps measure the organ dysfunction criteria of the respiratory, cardiovascular, coagulation, neurological systems. Mary, what are your thoughts on the new Phoenix depth of scoring criteria?
Speaker 2:Well, the first thing is, once it became familiar with the scoring, I immediately appreciated that the Phoenix score criteria really moves away from systemic infection, so SERS, and instead of it looks more like clinical, emphasizing, clinical judgment in organ dysfunction, which is in line with what we see with the adult criteria, and I think that the goal here is the approach is to offer a more targeted way to identify, you know, sepsis in the pediatric population. One of the things that caught my attention really is the whole notion of not using the SERS criteria. Tension really is the whole notion of not using the SERS criteria and you know what they said in the statement is SERS is overly sensitive really is what they're saying and it often flags many cases that lack true clinical significance, which kind of makes it more difficult to pinpoint those that truly for us, for my team I always bring it back to my team, right, CDI it makes it more difficult to pinpoint those that truly warrant a query. So now, with a better understanding of the Phoenix model, I see it as a potential to improve documentation accuracy and help us better identify cases that reflect true sepsis, rather than simply reacting to sort of broad physiological triggers. This also does fall in line with step three in the adult population. So to me it made sense and I think the aim to improve early recognition and risk stratification aligns more closely with those adult contemporary sepsis definitions.
Speaker 2:For our CDI query writing team the approach aligns with how we already address a lot of our sepsis cases, which we observed. We work in a lot of hospitals over 400. So we've observed that some hospitals are adopting the criteria and a lot of them are adopting the adult SEP3, especially when we are introducing sepsis through queries and meaning if we ask for sepsis in our group, it's retrospective and the criteria this new criteria guides on strong clinical indicators. One of the things that always comes to me my mind as well is when we go into hospitals, sometimes over the last three years folks weren't really even some people, some programs weren't reviewing the pediatric population and that's shifting. So I think the criteria are coming at a good point. Based on the AXIS 2024 CDI Week Survey, 49% of respondents currently review pediatric records and another five plan to expand next year. So that's this year. So most of the CDI reviewers are going to encounter pediatric sepsis and you know, as I know, cdi specialists like guidelines and frameworks. So that's sort of where my thinking is on it, lena.
Speaker 3:Yeah, and those are really interesting thoughts for me and I agree, I think that HEADS is definitely up and coming within CDI we saw such a huge focus on it even at the ACTIS conference this year and having its own track to follow and definitely came up a lot within the conference and so a lot of discussion I think was had within that.
Speaker 3:One question though that I had and I know you talked about SIRS it's hard for me to wrap my head around.
Speaker 3:I think, as a nurse, that SIRS is not going to be considered when we have, like evolving or developing sepsis, because to me sepsis is almost like an intuitive diagnosis.
Speaker 3:You know, being a nurse at the bedside, that was the first thing that popped up as something going on more with the patient than maybe a typical common infection. When we had those SIRS, abnormal values come up of heart rate, respiratory rate, temperature or even just immunologically. To me being those abnormal values, I was more attuned to recognize that the infection is progressing or evolving, and so I think it's going to eliminate some of the early recognition findings and may hinder the diagnosis and therefore hinder response and treatment, at least at first, just for organizations that do implement this and really use it as more of a screening tool, because that Phoenix Cessna score originally included the eight system model, so not just the respiratory, cardiovascular, coagulation, neurological, but also the endocrine, hepatic, immunological and renal. I think by focusing on the four system model they chose that they said because it was simpler and it achieved similar discrimination. But I think it's going to eliminate some of that evolving and early recognition of sepsis.
Speaker 1:So by excluding those organ systems, you feel that we're going to see a difference in the sensitivity. Are there implications like that?
Speaker 3:Yeah. So I know they selected the systems included by determining which organ dysfunction criteria was going to best predict mortality among children, and so these were to identify the sickest of the sick with any proven or suspected infection. But that excludes a lot of what we had considered organ dysfunctions in the past. And so again, if we only consider the four system model and we kind of pigeonhole that diagnosis, I think it's going to deter people from recognizing that there may be something more going on in a patient, for instance, if they have an increase in their glucose but they're not a diabetic patient but they have that infection and so it's increasing that endocrine system or they have an elevated creatinine. Are clinicians going to still consider that they're developing sepsis in the pediatric population in organizations that are going to utilize this Phoenix scoring system to define sepsis?
Speaker 3:I know the Phoenix scoring system was not developed to be a screening tool straight from their publication per the SCCM. However, the SOFA score in sepsis 3 was also not developed as a screening tool, but we do see it used conventionally in practice, sort of as a screening tool for sepsis and to prove that that sepsis is present or happening in patients and in some cases even integrated into their EHR to act as a prompt. When they have abnormal criteria that pop in and lab values are either entered or documented, combined with a documented infection presence, it's going to say, is this an organ dysfunction? And then maybe prompt the nurse or clinicians to say, hey, you may want to take a closer look at this.
Speaker 1:Wow, so you think the use of this criteria will make the leap into becoming a screening tool?
Speaker 3:In my opinion, absolutely, Mary. What do you think about that?
Speaker 2:I think we learn from history and there's true concern. I agree with what Lena is saying here. So while the Phoenix criteria offers like a more reframed framework for classifying pediatric sepsis, I'll say it again it was not designed for early recognition or screening and not to trigger even the initiation of antibiotics or early organ support. So it calls that out in this criteria. But to Lena's point, this is very similar to how sepsis three first hit the scene. The Phoenix criteria rely on the presence of organ dysfunction and it's intended to identify patients with more severe, clinically significant sepsis, not to flag cases in the early stage of infection. But we know how sepsis three grew legs, if you will, and started, you know, tentacles out there.
Speaker 2:There's a real risk with these criteria. This criteria could be misapplied as a screening tool, especially in settings where clinicians or CDI or documentation teams are eager for standardized methods so to identify sepsis. So I can see it happening. We've seen it happen in the adult population and using Phoenix in this way could lead to, as Lena said, under-recognition of early sepsis and missed opportunities for timely intervention, particularly in children who haven't developed that overt organ dysfunction but they're clinically deteriorating. So I think we have to use with caution and understand that this criteria cannot replace the assessment at the time by the physician provider and especially in the outpatient in the ED setting. So it is concerning Just have to know and keep talking about it. I think that's why these discussions are so important.
Speaker 3:Yeah, I completely agree, mary. I think there will also be Phoenix scoring limitations with any chronic condition presence in pediatrics, because the Phoenix scoring system doesn't specify that organ dysfunctions must be new. So in cases where they have coagulation issues or respiratory dysfunctions, how are they going to differentiate these baseline scores? You know, with acute conditions and changes it's going to be a trying time, I think, for clinicians and organizations as they go to adopt this. Another factor too that you know flags for me is that in pediatrics, when I've reviewed charts in pediatrics and as a CDI and I never worked as a nurse in pediatrics but I know that the pediatric population doesn't always have those four system approach indicators documented or recorded. And so having a Glasgow coma scale, an INR, a fibrinogen, a MAP or ABGs even you know to represent a PAO2, fio2 in PEDS isn't super common unless there's something else going on with the patient and so like with the Glasgow Coma Scale in PEDS, it's really difficult to measure based on that patient's developmental stage. It can be subjective. Nor is it always documented as a total GCF score but maybe rather separated into common components of the GCF or even individually documented in the assessment and finding without a score. So that leaves a lot open to interpretation.
Speaker 3:And then it not being consistently documented. Documented just like blood pressures and maps. I mean, as we all know and understand, and I know people that haven't been at the bedside blood pressures trying to get those on a fussy three-year-old who is uncomfortable and being hooked up to equipment in an unfamiliar environment. All these people are around, up to equipment in an unfamiliar environment. All these people are around. You know it's often inconsistently completed documented. And if it is documented it may not have a map calculation. And so same thing with the lab values INR, fibrinogen, abgs. You're just not really going to have that drawn and ordered and there for you to assess if there's something not lagging them, to require those different lab values and to draw them on that patient.
Speaker 1:Oh, do you feel that that's going to limit the identification of sepsis? Then?
Speaker 3:I believe this will significantly impact the identification of sepsis, especially early on in organizations that choose to implement this as a criteria-based screening tool. Just like Mary said, as we saw with sepsis 3, it definitely grew legs, and people like frameworks and they like black and white. You know this is how we're going to define and diagnose something, but you know, as I said before, sepsis is very intuitive. It's very much. You know what that patient looks like in the moment and what they're going through and how they appear, and so this isn't only going to be challenging for clinicians, it's also going to be challenging for coding and CDI, because I think there will be changes based on this criteria in how CDI write queries, what they should include when validating or seeking clarification on pediatric sepsis, Because severe sepsis never caught up in the ICD-10 coding world. How is this going to affect ICD-10 going forward? We still have that ICD-10 code of severe sepsis, but that's not indicated in sepsis three or supported in this new Phoenix sepsis scoring system. Mary, what do you think about that?
Speaker 2:Yeah, I agree. And for clinical documentation integrity, I think it's important to understand and educate our teams. And when I make tip sheets, you know when this first came out it was like a mad scramble to read the JAMA article and get the you know tip sheets going. So really I start with Phoenix equals classification, not detection. So that's the important thing and I don't know how we control that, but we just have to keep saying it and it should be used to support diagnostic clarity and documentation accuracy after a clinical picture of infection and organ dysfunction has emerged, not as a frontline screening checklist, so that you know.
Speaker 2:I think, lena, you pointed out the pitfalls that we anticipate will happen and when we're teaching our CDI teams, we have to teach them they should not rely solely on Phoenix criteria for query or diagnosis validation queries. You know we're still going to be looking for the physician to document a clear link of you know evidence of infections, clinical signs and symptoms, including, but not limited to, just the organ dysfunction. So it's supportive right, the scoring and really it's the provider clinical judgment that the child meets for sepsis. That's important. I think it's going to take education to physicians and teams that for the Phoenix tool, that it is a classification tool and it's also shouldn't be a coding or reimbursement standard and or CDI standard, that you must have all of those things to query for sepsis, but that's, you know, sort of.
Speaker 2:What we're in the middle of now is putting those policies together, and physician documentation should still stand on their own clinical rationale, not just the scoring tools. That's, you know, my opinion and that's kind of what I, what my thought is on that, and even though you know the other thing is, even though the score only includes four systems, there were eight, and those are still clinical indicators that, if present, you would include in your query. Lena, what do you think?
Speaker 3:I completely agree that you cannot disclude those from a query, because it does point out to something going on more than just the infection. So totally agree.
Speaker 1:Do either of you feel that payers will start to use this as ammunition and denials? Should this be incorporated into contractual revisions?
Speaker 3:So again, yes, I absolutely think that and predict that they will be using this in denials, just as we see now, with payers utilizing whichever sepsis criteria behooves them most to deny claims in any given case. You know so if you have a sepsis three supported case, they're going to deny you a sepsis two, and vice versa. So I absolutely predict payers attempting to use this criterion as a denial mechanism, and I've always believed stakeholders in the mid-revenue cycle should always have a seat at the table during contractual revisions, including CDI and coding leaders, because this is exactly why someone who is looking at these charts and seeing what is going on, how we're billing, what contracts are getting supported or denied based on claims that they're getting submitted. It has to benefit patients and organizations too, and not only the payers. And so, having that broad sense of defining a diagnosis, any diagnosis Providers have the prerogative to diagnose the patient based on their medical opinion, and it can't be again, you know, pigeonholed into a single viewpoint and contractual language that prevents the clinician who is treating the actual patient at the bedside from accurately diagnosing the patient.
Speaker 3:I think those links have to be there, just like Mary said, but you know, from a even from a quality standpoint.
Speaker 3:You know this is going to have to come from providers saying you know, this patient has sepsis and we're going to treat it like sepsis, and this all could turn into quite a mess because this can definitely impact septic bundle management quality measures.
Speaker 3:You know, as we all know, patients have a choice now in their care and where they receive treatment. Quality scores are publicly reported data and so you know, the public relies upon that data to say you know, I'm going to go to hospital A over hospital B, upon that data to say, you know, I'm going to go to hospital A over hospital B. And if sepsis has, like we talked about before, a limited capture as a diagnosis based on the Phoenix scoring system use, it can really create a cascading effect because those outliers are going to have a significant impact on overall quality metrics, severity reporting and then misrepresent the quality of care being provided, which can in turn affect financial incentives or reductions of organizations. All based on, you know, cms, cmi calculations and then any value-based or pay for reporting programs that they're within. What do you think, mary? I definitely think you have an opinion on this, yeah and it's right in line with yours.
Speaker 2:Really, the risk mirrors what happened with SEP3 in adults, where we had payers begin to use that criteria to challenge claims, even though SEP3 is not the official CMS standard.
Speaker 2:So hospitals are caught in the middle. There's a real potential risk in how insurers may eventually interpret and misuse the criteria, much like we've already seen. One of the things that happened with SEP3 denying adult claims that was successful in the Northeast was the hospital associations getting together, the associations getting together with hospitals to create statements for the insurance companies. Back to the denying insurance companies and standing together. And that's, you know, right in line with what Lena said about a seat at the table, we have to have a voice. Right in line with what Lena said about a seat at the table, we have to have a voice, you know. And so that, despite SEP3 never being formally adopted by CMS for coding or reimbursement purposes, several payers, you know, started referencing it just to justify denials, arguing the cases without the documented organ dysfunction didn't meet the clinical threshold for sepsis, regardless of the treating physician's judgment or the patient's clinical perception. That's, an insurance company diagnoses a diagnosing and that's just not fair. So I agree with Lena on this.
Speaker 3:Yeah, I a hundred percent agree. It's not fair. It has to be based on the physician's judgment. That's there, you know, in their medical opinion for sure. But to point out to you, very recently, in April of 2025, I know we said CMS never officially said that's this.
Speaker 3:Three is the definition of sepsis, but the government accountability office released a report to congressional committees on sepsis incidents and management and within the Department of Defense's health agency is where they were focused, and so this report actually did release a definition of sepsis and it had the same information as sepsis three actually even references sepsis three in the report, and so we know that's that life-threatening organ dysfunction caused by the dysregulated host response, you know, to an infection.
Speaker 3:Two or more SOFA scoring, but that's interesting because it includes the renal and hepatic systems, but the Phoenix scoring system does not, and so this is kind of big because that definition that they included is based on data pulled from the DOD health systems, and these DOD health systems and these DOD health systems include DOD beneficiaries and of which, within that report, 6% of them were under 18 years of age.
Speaker 3:So this is the pediatric population that they're saying. You know we're using SOFA scoring sepsis, three criteria to look at. And you know this is a government agency defining sepsis. So, even though the GOA is not BMS nor does it have anything to do with ICD-10 coding, it is a government agency taking a stance on defining sepsis. So you know of all the other governing bodies that are government agencies, like CMS, payers, hrq, psis, cdc, joint Commission, things like that I think they're going to be well attuned to looking at this report and supporting sepsis three, you know, as a definition, and because they included the pediatric population, I don't know what that's going to look like for the Phoenix scoring system.
Speaker 1:That's really interesting. So you think it will make the leap to CMS and that, with many children across the US utilizing Medicaid, will they impact sepsis and pediatrics?
Speaker 3:utilizing Medicaid that they'll impact sepsis in pediatrics. There's definitely a strong possibility that this is going to snowball and affect the overall payments we see and or denials in the pediatric setting overall, like we've talked about, and that's regardless of the addition of the Phoenix scoring system. Will it help prevent the use of the Phoenix scoring system as a screening tool for sepsis? I don't know. We're definitely going to be finding out in the near future, I think.
Speaker 1:Mary, do you have some thoughts about that?
Speaker 2:Yes, I think you know there's a lot remaining to be seen and I know the intention of the criteria was to get more specificity and you know, to get more specificity and when you've already identified right, so not to screen, I think it's. You know, right now payers aren't broadly using the Phoenix criteria to deny pediatric sepsis claims, but it's still relatively new and, as Lena pointed out, it's not officially endorsed yet by CMS or payers as a coding or reimbursement standard. However, you know we, as we've said I mean I don't want to be repetitive here, but we do learn from the very recent past if, if a similar pattern emergence with the phoenix criteria, p cases could be denied based on documentation not representing organ dysfunction in those four areas, not even if it's appropriate, you know, if the physician appropriately diagnosed and treated the patient. So we just have to keep an eye on it. I think also it could particularly impact borderline or early sepsis cases where clinical judgment still plays a really key role and Phoenix organ dysfunction may not be fully evident as it's evolving right. So you know, I just think we have to keep hammering the point that the Phoenix criteria was not designed to be used for reimbursement or coding decisions. They're intended as a clinical classification tool. You know, easier said than done We've seen payers have previously extrapolated clinical tools beyond their intended use and without clear carton rails. I mean they may begin using Phoenix criteria as an unofficial standard to challenge documentation and claims, and so that that's going to be interesting. We'll see what happens.
Speaker 2:But I think it's critical that providers continue to document their clinical rationale clearly, especially when sepsis is diagnosed, and if there's not overt organ dysfunction, they need to clearly document their indicators, cdi and coders. We really shouldn't over-rely on Phoenix scoring when reviewing documentation for code assignment and hospitals. I think and compliance teams need to stay proactive and monitoring any denial trends and we prepare appeal strategies as a group. Right, there's power in numbers. So those consensus statements, if we can get hospital associations and hospitals together, are powerful. So, yeah, I think that it's just, it's going to be interesting and the CDI appeal team will have to be ready. Yep, I agree.
Speaker 1:That's amazing. It's a wonderful discussion. I really appreciate it. It's terrific to have both of you on our program. I'd like to thank my guests, mary McGrady and Lena Belcher, for joining me to discuss the updated pediatric sepsis definition and the Phoenix scoring system update. I'm your host, bill Hancock, and thank you for listening to our discussion. At Acuity, we're transforming healthcare reimbursement with a provider-driven, innovative approach. We share valuable clinical and coding insights and current best practices to improve financial outcomes across health systems. If you have any questions or would like to offer a topic to discuss, please email info at acuityhealthcarecom. Opinions expressed in this production are those of the host or guests and do not represent official stances of Acuity. The suggestions, advice and guidance provided by the individuals featured in this podcast are not intended to replace any medical advice, consultation or treatment you may receive from your healthcare provider.
