CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP041

Sepsis Policy

This document governs coding, billing, and claim review practices 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 TypeCoding guidance addedoperational edits

Effective DateJan 7, 2025

Next Review Date

Key ActionUpon request, submit supporting medical record documentation to validate sepsis coding for claims review.

SourceLink

POLICY UPDATE CHANGES

Plan-specific additions to ICD-10-CM sepsis coding guidance were included.

MS-DRG code chart removed.

References updated.

1.0policy version

Jan 7, 2025Plan effective date

12/12/2024Last review date

3key definition terms

Sepsis Coverage Criteria

Sepsis coding and documentation criteria

Claims will be reviewed for evidence supporting sepsis coding and must contain documentation that supports the diagnosis and treatment.

Documentation must support the diagnosis billed and accurately describe services rendered; the plan may request supporting medical record documentation to substantiate the claim.

ALL of the following

Documentation must show evidence of infection (may include provider statement of viremia, fungemia, or other infection even when blood cultures are negative or inconclusive).
Documentation must show evidence of end-organ dysfunction triggered by a dysregulated host response to infection (Sepsis-3 definitions used as basis).

Organ dysfunction that is part of sepsis should not be coded separately when coding sepsis; assign organ dysfunction codes only as additional acute dysfunctions when applicable and consistent with guidance.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySepsis Policy

Policy CodePolicy CPCP041

Change TypeCoding guidance addedoperational edits

Effective DateJan 7, 2025

Next Review Date

Key ActionUpon request, submit supporting medical record documentation to validate sepsis coding for claims review.

SourceLink

On This Page

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Coding and Sequencing Guidance

ICD-10-CM codes referenced in sequencing guidanceICD-10Covered

R65.21	Severe sepsis with septic shock (as referenced for sequencing guidance)
T81.12	Postprocedural septic shock (as referenced for sequencing guidance)

Sequencing rule for septic shock (inv-03)

Sequencing requirementWhen septic shock is coded, sequence the systemic infection code first, then R65.21 or T81.12; assign additional acute organ dysfunction codes as applicable.

Principal diagnosis restrictionA code from subcategory R65.2 can never be assigned as the principal diagnosis.

Additional organ dysfunction codingOther acute organ dysfunction codes may be assigned in addition to R65.21 or T81.12 when applicable.

Provider Responsibilities and Claim Review

Documentation Required

Respond to documentation requests and support billed diagnosis

Upon request, the plan may require submission of supporting documentation from the provider. Claims are reviewed on a case-by-case basis using the member's medical record documentation and the sepsis criteria in this policy; documentation submitted must support the diagnosis billed and failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Documentation must demonstrate evidence of infection and end-organ dysfunction as described by the sepsis criteria in this policy.
Submit additional medical record documentation when requested by the plan to substantiate sepsis coding.

Billing Rule

Expect code edits and claim review per contract and plan rules

Claims are subject to code edit protocols and claim review, including review against provider contract language, plan benefit terms, clinical payment and coding policies, and coding software logic; providers are responsible for submitting accurate, appropriately coded claims.

Use valid HIPAA-approved code sets and follow industry-standard coding guidelines (ICD-10-CM, CPT, CMS NCCI, UB, DRG rules, etc.).
Be aware that edits and contract terms may modify reimbursement or deny services if coding/billing policies are not followed.

Key Definitions

Sepsis (inv-06)

DefinitionLife-threatening organ dysfunction caused by a dysregulated host response to infection; in lay terms, sepsis is a life‑threatening condition that arises when the body's response to an infection injures its own tissues and organs.

Documentation requirementClaims must contain documentation that supports the diagnosis and treatment of sepsis (evidence of infection and organ dysfunction).

Coding noteOrgan dysfunction is a component of the sepsis definition and should not be coded separately when coding sepsis.

Septic Shock (inv-07)

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

Relation to organ dysfunctionSeptic shock generally refers to circulatory failure associated with severe sepsis and represents a type of organ dysfunction evidenced by hypoperfusion and/or hypotension.

Sequencing guidanceWhen septic shock is present, sequence the systemic infection first, then R65.21 or T81.12; additional acute organ dysfunction codes may be assigned.

Coding restrictionR65.2 subcategory codes cannot be the principal diagnosis.

SIRS (inv-08)

DefinitionSystemic inflammatory response syndrome (SIRS); may be used for screening but is not adequate for coding sepsis.

Use in practiceAppropriate for initial screening for systemic inflammation but insufficient alone to support sepsis coding without evidence of organ dysfunction and infection.

MAP (inv-09)

DefinitionMAP stands for mean arterial pressure.

Clinical relevanceMAP is a physiologic measure commonly referenced when assessing perfusion and hypotension in sepsis and septic shock.