Updates on NOTICE, Sepsis-3, and hypertensive crisis

CMS takes action on several recently covered topics.

Recent actions by CMS have affected multiple topics recently covered in this column, including communicating with patients about observation status and documenting sepsis and hypertension.


The July Coding Corner explained the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which required that Medicare beneficiaries who receive observation services for more than 24 hours be given oral explanation and written notification of their inpatient or observation status within 36 hours of initiation of observation services or upon release.

On Aug. 2, in the 2017 Inpatient Prospective Payment System final rule, CMS announced a delay in implementation of the Act. The agency submitted a revised version of the required notice to beneficiaries, the Medicare Outpatient Observation Notice (MOON), for public comment before it would receive final approval. The provisions of the NOTICE Act must be implemented for all Medicare beneficiaries, using the MOON, within 90 days of final approval.

Photo by Thinkstock
Photo by Thinkstock

In response to already received public comments, CMS has reduced the number of required fields on the MOON, removing physician name, the date and time observation services began, and the field for the hospital name. Hospitals will be permitted to preprint the MOON to include the hospital name and logo at the top. CMS also removed the Quality Improvement Organization contact section from the MOON due to concerns that it might unnecessarily prompt a flood of complaints about the nature and quality of care provided.

In response to public comment that the MOON language regarding coverage of posthospital skilled nursing facility care and Part B coverage should be clearer and more prominent, CMS has simplified this text and moved it near the top of the notice. In addition, CMS has added a free-text field where the specific reason for the patient receiving observation services must be completed by the hospital.

CMS noted that while the Act does not require notice until 24 hours of observation have been provided, hospitals may voluntarily deliver notice before that deadline to ensure compliance. CMS does not recommend providing notice when observation services are initiated, citing concerns that patients may be preoccupied with their health care needs and other paperwork at that time.

Some states independently require notice of outpatient status for all outpatients, regardless of the payer and irrespective of whether the patient has received observation services, and some require notice within 24 hours. CMS notes that, in some cases, delivering the MOON to Medicare patients under observation may also fulfill state notice requirements, but hospitals will need to make that determination on a state-by-state basis.

The revised MOON (Form CMS-10611) and notice instructions can be accessed online.


The controversy over the new Sepsis-3 criteria was discussed in the March and June editions of Coding Corner (as well as in the August ACP Hospitalist). discarded the concept of systemic inflammatory response syndrome (SIRS) as the basis for diagnosing sepsis and eliminated the distinction between sepsis and severe sepsis.

On July 26, 3 physician representatives of CMS published a letter in JAMA announcing that despite the release of Sepsis-3, CMS will not change the sepsis definitions in its SEP-1 sepsis management inpatient quality measure. The definitions used in the SEP-1 measure, which the letter described as “widespread and understood,” consider sepsis as SIRS due to an infection and severe sepsis as sepsis with acute organ dysfunction.

CMS pointed out that clinical practice measures require “extensive real-world field testing to assess reliability, usability, and feasibility” and that “the SEP-1 measure underwent more than 8 years of development and critical review” and is supported by a large body of clinical evidence.

While the authors welcomed “new research and innovative thinking,” they said that “prior to changing the widespread and understood definitions used in SEP-1, rigorous clinical investigation will be required....”

Other reservations concerning the proposed Sepsis-3 definitions expressed in the letter included the potential for delayed diagnosis of sepsis, disruption of the current trend of decreasing sepsis mortality, and negative effects on ongoing quality improvement efforts.

Along with the CMS response were published other letters expressing concerns about Sepsis-3, focusing on potential flaws in methods and statistical analysis and the need for prospective studies to substantiate the real-world clinical validity of the new Sepsis-3 definitions. The CMS letter promised the agency would track the research that the new “proposed definitions will inspire.”

Hypertensive crisis

When ICD-10-CM took effect last year, one of the most surprising changes was the elimination of specificity for hypertension, as discussed in the November 2015 Coding Corner. That has changed with the release of the 2017 Inpatient Prospective Payment System final rule on Aug. 2.

Codes for the spectrum of hypertensive crisis have been restored. Hypertensive crisis is a general term intended to encompass both 1) hypertensive urgency with marked elevation of blood pressure requiring prompt intervention and 2) more serious, potentially life-threatening hypertensive emergency requiring immediate aggressive intervention.

Hypertensive urgency is characterized by systolic blood pressure (SBP) greater than 180 mm Hg or diastolic blood pressure (DBP) greater than 110 mm Hg with symptoms such as headache, dyspnea, or chest pain but without end-organ involvement. Hypertensive emergency is distinguished by SBP greater than 180 mm Hg or DBP greater than 120 mm Hg with end-organ involvement such as neurologic, renal, or cardiac systems. Obviously, there can be some gray areas in terms of SBP and end-organ involvement.

In the past, ICD-9-CM had codes for hypertensive crises described by the archaic terms “malignant” and “accelerated” hypertension. At its launch, ICD-10-CM inexplicably had no codes to identify this serious condition; all hypertension other than maternal and that due to heart or kidney disease was assigned to a single code, I10, having no significant impact on severity.

Thankfully, new codes have been created for these conditions, incorporating current clinical terminology:

  • I16.0 (hypertensive urgency)–no diagnosis-related group (DRG) or severity impact
  • I16.1 (hypertensive emergency)–impacts DRG and severity level
  • I16.9 (hypertensive crisis)–impacts DRG and severity level

It is not clear why the general, nonspecific term “crisis” is considered significant while “urgency” is not, even though clinically “urgency” is included under the term “crisis.” In any case, for proper documentation, the correct clinical terminology should be used to describe the specific circumstances encountered with each individual patient. If the patient meets clinical criteria for hypertensive urgency, but not hypertensive emergency, the condition should not be described as emergent. Whether to use “urgent” (no severity impact) or the general term “crisis” (having severity impact) is left to the clinician's judgement.

Clinicians will have to “unlearn” the terms “malignant” and “accelerated,” which have been emphasized for proper code assignment for so many years. These terms should not be used since they are outdated and poorly defined and have been replaced with current terminology.