CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP041

Sepsis Policy

Governs coding, billing, and claim review for sepsis-related services for Blue Cross Blue Shield of New Mexico members and providers submitting claims to the plan.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySepsis Policy

Policy CodePolicy CPCP041

Change TypeNo material changes

Effective DateJul 16, 2024

Next Review Date

Key ActionProviders must submit supporting medical record documentation to substantiate infection, organ dysfunction, and the treatment course for claims under review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

07/16/2024effective

DRGs 853-872DRG review

Sepsis3 + CMSguidance sources

Sepsis Claim Review Criteria

Sepsis claim documentation and coding criteria

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Claims must include documentation in the member's medical record that supports the diagnoses billed and accurately describes the services rendered.

ALL of the following

Examples of acceptable documentation
- Positive microbiology (when present) or provider statement documenting evidence of infection for conditions where cultures may be negative (e.g., viremia, fungemia).
- Clinical findings and provider assessment consistent with an infectious process documented in the record.

ALL of the following

Evidence of organ dysfunction may include
- Organ dysfunction descriptors in the medical record (e.g., hypoperfusion, hypotension, need for vasopressors, altered mental status, acute renal dysfunction, respiratory failure).
- Clinical measurements and interventions consistent with organ dysfunction (e.g., vasopressor use, mechanical ventilation, acute dialysis).

Treatment course documented must be consistent with the type and severity of the infection and organ dysfunction described.

Coding and sequencing must follow plan guidance: when septic shock is present, sequence the code for the systemic infection first, followed by R65.21 or T81.12; a code from subcategory R65.2 cannot be the principal diagnosis.

Organ dysfunction that is part of the sepsis definition should not be coded separately except when additional acute organ dysfunctions are present and supported by documentation; any such additional acute organ dysfunction codes should be assigned in addition to the infection and R65.21/T81.12 when applicable.

Claims associated with MS-DRG codes 853-872 are subject to plan review; the plan will review principal and secondary diagnoses affecting DRG assignment.

The plan may request supporting documentation and will review claims on a case-by-case basis; failure to provide documentation that supports the diagnosis billed may affect claims processing and reimbursement.

Diagnosis Codes and Sequencing Guidance

Sepsis-related diagnosis codes and sequencing guidanceICD-10

R65.21

Severe sepsis with septic shock (referenced for sequencing guidance)

Sequencing guidance and notesmixed

Sequencing rule

Code for the systemic infection should be sequenced first, then followed by R65.21 or T81.12; a code from subcategory R65.2 can never be assigned as a principal diagnosis. Any additional acute organ dysfunction codes should also be assigned.

MS-DRG codes subject to review (examples)Revenue

853	Infectious and parasitic diseases with O.R. procedures with MCC.
854	Infectious and parasitic diseases with O.R. procedures with CC.
855	Infectious and parasitic diseases with O.R. procedures without CC/MCC.
856	Postoperative or post-traumatic infections with O.R. procedures with MCC.
857	Postoperative or post-traumatic infections with O.R. procedures with CC.
858	Postoperative or post-traumatic infections with O.R. procedures without CC/MCC.
870	Septicemia or severe sepsis with MV > 96 hours.
871	Septicemia or severe sepsis without MV > 96 hours with MCC.
872	Septicemia or severe sepsis without MV > 96 hours without MCC.

Sequencing rule for septic shock

Sequencing orderWhen coding septic shock, sequence the code for the systemic infection first, then assign R65.21 (severe sepsis with septic shock) or T81.12 as applicable.

Additional organ dysfunctionsAssign additional code(s) for any other acute organ dysfunctions in addition to the infection and R65.21/T81.12.

Principal diagnosis restrictionA code from subcategory R65.2 (severe sepsis codes) can never be assigned as the principal diagnosis.

Context of sequencingSeptic shock generally refers to circulatory failure associated with severe sepsis and represents a type of organ dysfunction (hypoperfusion and/or hypotension); sequencing follows this clinical relationship.

Documentation Requests and Claim Review Actions

Documentation Required

Documentation requests and claim review

Providers are responsible for submitting accurate, complete documentation that supports the diagnosis and services billed. Upon request, the Plan may require submission of medical records and any additional supporting documentation to substantiate the diagnosis, evidence of infection, evidence of end‑organ dysfunction, and the treatment course. Documentation must support the codes and code combinations reported and conform to industry coding guidelines (e.g., UB, AMA CPT, HCPCS, ICD‑10‑CM/PCS, NDC, CMS NCCI).

Providers must submit claims using valid HIPAA‑approved code sets and appropriate code combinations.
Documentation should demonstrate evidence of infection and, when applicable, end‑organ dysfunction consistent with sepsis definitions and the Plan's coding guidance.
Failure to provide requested documentation or to adhere to coding/billing policies may result in claim adjustment or denial and impact reimbursement.

Denial Risk

Claim review authority and potential denial risk

Claims are subject to review under code edit protocols, provider contract terms, benefit coverage rules, medical and clinical payment/coding policies, and coding software logic. The Plan reviews sepsis‑related claims on a case‑by‑case basis for evidence that supports the billed diagnosis and sequence of codes (for example, sequencing of systemic infection and R65.21 when applicable). Providers should be aware that plan documents and provider contracts govern when conflicts exist, and the Plan has discretionary authority to interpret and apply policy.

Claims will be reviewed for compliance with CMS ICD‑10‑CM Official Guidelines and the Plan’s additional sepsis coding instructions (e.g., organ dysfunction coding, sequencing rules for septic shock).
Claims are subject to code edit protocols including CCI table edits and other CMS guidelines.
Providers may be asked to submit additional information; lack of adequate documentation may lead to denial or recovery of payment.

Key Clinical Definitions

Sepsis

DefinitionLife-threatening organ dysfunction caused by a dysregulated host response to infection.

Clinical significanceRepresents a condition where the body's response to infection injures its own tissues and organs; claims must document infection and organ dysfunction.

Documentation requirementClaims will be reviewed for medical record evidence of infection, organ dysfunction from a dysregulated host response, and treatment consistent with the infection type.

Septic Shock

DefinitionSubset of sepsis with underlying circulatory and cellular/metabolic abnormalities profound enough to substantially increase mortality.

Relation to severe sepsisSeptic shock generally refers to circulatory failure associated with severe sepsis and is considered a type of organ dysfunction (e.g., hypoperfusion or hypotension).

Coding noteWhen present, sequence the systemic infection code first, then R65.21 or T81.12; include additional codes for other acute organ dysfunctions as needed.

SIRS

DefinitionSystemic inflammatory response syndrome (SIRS).

Use in practiceMay be appropriate for screening for sepsis but is not adequate for coding sepsis.

Coding implicationDo not rely on SIRS criteria alone to assign sepsis diagnosis codes; documentation must support sepsis definitions per Sepsis-3/CMS guidance.

MAP

DefinitionMean arterial pressure (MAP).

Clinical relevanceMAP is referenced in definitions/terms within the policy and is a standard hemodynamic measure relevant to circulatory failure and septic shock assessment.

Documentation noteInclude MAP measurements in the medical record when relevant to support circulatory dysfunction or septic shock claims review.