Payment Policy: Sepsis Diagnosis
Customize your policy alerts
Sign up for Arizona Complete Health Policy CC.PP.073 alerts
Get alerted when Policy CC.PP.073 changes without checking for updates manually.
Monitor payer policy activity
Governs documentation, coding validation, and pre-/post-pay review for inpatient hospital claims with a sepsis diagnosis for Arizona Complete Health members aged 18 and older.
No material clinical or coverage changes in this revision.
Sepsis Documentation, Validation, and Coverage Rules
inv-01: Sepsis documentation, validation, and audit criteria
Covered when ALL of the following documentation and clinical validation criteria are met:
Documentation requirement per policy overview and documentation requirements.
Clinical definition referenced for validation.
SOFA ≥2 requirement and imputation approach.
Treatment evidence required in documentation.
Excluded definitions for validation.
Audit initiation and medical record request process.
Clinical validation workflow and roles.
Notification and dispute process.
Turnaround time and EOP communication.
inv-02: Coverage guidance and precedence
Coverage and payment determinations follow this policy in conjunction with the member’s plan documents and any applicable state or federal requirements.
Policy purpose and limitations; plan documents govern.
State Medicaid precedence for Medicaid members/enrollees.
Medicare NCD/LCD coordination and precedence.
Provider responsibilities and limits of the policy.
ICD-10 Codes, Clinical Thresholds, and Coding Notes
| R65.20 | Severe sepsis without septic shock |
| R65.21 | Severe sepsis with septic shock |
| A41.9 | Sepsis, unspecified organism |
| T81.44XA | Sepsis following a procedure, initial encounter |
| A41.54 | Diagnosis code added to ICD-10 table (as noted in revision history) |
| T81.44XA | Code added earlier to ICD-10 coding table (referenced in revision history) |
Provider Responsibilities, Reviews, and Coordination
Pre- and post-pay review and medical record requests
Claims with a sepsis diagnosis will be reviewed on either a pre- or post-pay basis. When a potential billing error is identified, the Health Plan will request medical records to validate the diagnosis and procedure codes billed on the claim. Once the medical record is received, certified professional coders and clinicians will clinically validate the documentation to ensure the medical record contains the necessary information and that the diagnosis billed on the claim is supported by the clinical information in the medical record, including medical interventions. After review, the Health Plan will issue an audit determination letter to the provider if sepsis was diagnosed/billed in error; the letter will explain the determination and provide details for submitting a dispute if the provider disagrees. The clinical validation review will be completed within 60 days from receipt of medical records. Explanation codes will be sent to the provider on the Explanation of Payment (EOP) at the conclusion of the review.
- Review timeframe: clinical validation completed within 60 days of receipt of medical records
- Providers will receive an audit determination letter and EOP explanation codes after review
Provider responsibilities and policy purpose
Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members/enrollees. This payment policy is a guide to payment and is not intended to dictate clinical practice, constitute medical advice, or guarantee payment. Providers referred to in this policy are independent contractors and are not agents or employees of the Health Plan.
Coordination with Medicaid/Medicare rules
Coordination with government programs: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with this payment policy, state Medicaid provisions take precedence; refer to the applicable state Medicaid manual for coverage details. For Medicare members/enrollees, review all applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) prior to applying the criteria in this payment policy to ensure consistency; refer to the CMS website (http://www.cms.gov) for more information.
- Medicaid precedence: state Medicaid manual governs when conflicts exist
- Medicare consistency: review applicable NCDs and LCDs before applying this policy
Key Definitions and Operational Criteria
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.