A recent case involved a Medicare-eligible plaintiff who was a medically fragile resident of a nursing facility, largely immobile and dependent on staff for repositioning, hygiene, and routine monitoring. As with many of the nursing home cases Paramount handles, during the plaintiff’s stay, a sacral pressure ulcer developed. The ulcer was documented in the chart, staged appropriately, and followed up with ongoing wound care assessments, per the medical records provided.
However, weeks later, he was rushed to the hospital after exhibiting fever and respiratory distress. Upon admission he was diagnosed with sepsis, with the hospital record also listing the sacral pressure ulcer as a secondary diagnosis.
When the claim data was processed through Medicare’s system, Medicare issued a Conditional Payment Amount (CPA) of $81,485.92, premised on the assumption that the hospitalization was related to the pressure ulcer that had developed during the nursing home stay.
On its surface, the implied narrative seemed both logical and legally consequential: a dependent resident developed a pressure ulcer, the ulcer becomes infected, the infection progresses to sepsis, and Medicare pays for a hospitalization that is causally tied to alleged neglect, thereby triggering reimbursement rights under the Medicare Secondary Payer framework.
But when the clinical record was reviewed more closely, a different story emerged. Instead of looking at isolated billing codes, Director of Lien Operations, Ajka Kudic, analyzed the records as one continuous timeline, and that told a materially different story.
The Assumption Embedded in the Coding
In nursing home litigation, sacral pressure ulcers often carry evidentiary weight because they are visible injuries that may be associated with lapses in care, and when sepsis follows, the temptation — particularly within administrative coding systems — is to connect the two without independently verifying the infectious source.
The hospital’s inclusion of the pressure ulcer as a secondary diagnosis did not explicitly state that it was infected, nor did it confirm that it was the source of bacteremia, but its presence in the diagnostic hierarchy was enough to influence the conditional payment analysis.
Coding, however, is not causation, and diagnosis sequencing does not substitute for clinical proof.
Reconstructing the Medical Timeline
A detailed review was undertaken, not limited to discharge summaries but extending to:
- Nursing home wound care documentation
- Weekly skin integrity assessments
- Progress notes reflecting wound status
- Infectious disease consultations
- Laboratory culture reports
- Admission history and physical examinations
The sacral pressure ulcer was present, documented, and treated, but there were no clinical indicators of infection: no purulent drainage, no expanding erythema, no systemic inflammatory response attributed to the wound, and no positive wound cultures linking it to bacteremia.
At the same time, the hospital admission materials revealed a consistent and well-documented pulmonary process, including radiographic evidence of pneumonia, respiratory findings preceding systemic decline, and physician documentation explicitly identifying pneumonia and lower respiratory tract infection as the infectious source precipitating sepsis.
The admitting physician’s assessment clearly stated that the sepsis was secondary to pneumonia, and the laboratory and imaging findings supported that conclusion.
In short, the infection began in the lungs, not in the sacral wound.
Why That Distinction Controls the Lien Outcome
Under the Medicare Secondary Payer statute, Medicare is entitled to recover payments only for care that is “related” to the injury or condition alleged in the claim, and therefore the determination of causation is not academic — it directly governs reimbursement exposure.
If the sepsis had originated from an infected pressure ulcer attributable to negligent care, then the hospitalization costs would have been causally connected, and the $81,485.92 amount may have been justified.
However, because the sepsis was clinically attributable to pneumonia — a separate and unrelated infectious process — the majority of the hospitalization charges were not properly recoverable under Medicare’s lien rights.
This was not a matter of negotiation leverage, equitable reduction, or compromise; it was a matter of medical accuracy.
The Dispute and the Correction
The dispute submission required a comprehensive causation summary, correlating physician documentation, diagnostic imaging, culture results, and clinical assessments, while clarifying that the presence of a pressure ulcer in the diagnostic list did not establish it as the infectious source.
By reframing the record around documented medical findings rather than billing sequences, the asserted Conditional Payment Amount was reduced from $81,485.92 to $476.66.
The remaining balance reflected minor related items, while the hospitalization for sepsis, previously assumed to be ulcer-related, was removed from the recoverable total.
The Larger Implication for Nursing Home and Sepsis Cases
In cases involving pressure ulcers, infection, and hospitalization for sepsis, administrative coding frequently creates a narrative that appears internally consistent but is not clinically verified, and when that narrative goes unchallenged, it can materially distort case valuation and net recovery.
An $81,000 overstatement affects mediation strategy, settlement analysis, and client expectations. It can also unnecessarily depress resolution value if accepted without scrutiny.
The broader lesson is straightforward but critical:
Secondary diagnosis codes do not establish causation, and assumptions about infection sources must always be tested against the full medical chronology.
When the medical story is reconstructed carefully with attention to documented infectious origin, objective findings, and physician attribution, reimbursement exposure often changes dramatically.
In this matter, the difference between $81,485.92 and $476.66 was not a negotiation tactic or a discretionary reduction; it was the product of Paramount’s understanding of nursing home cases and record analysis, precise causation framing, and a refusal to allow coding shorthand to dictate a negative financial outcome for the plaintiff.
