CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPO41

Sepsis coding and billing guidance

Governs coding and billing for sepsis-related services and treatment claims for Blue Cross Blue Shield of New Mexico members; affects providers submitting claims to BCBSNM.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySepsis coding and billing guidance

Policy CodePolicy CPCPO41

Change TypeNon-material operational updates

Effective DateJan 7, 2025

Next Review DateN/A

Key ActionSubmit requested supporting documentation promptly; ensure medical records and provider statements clearly document infection and organ dysfunction to support coded diagnoses.

SourceLink

POLICY UPDATE CHANGES

Ad-hoc review removed MS-DRG code chart and updated references.

CPCPO41identifier

1.0version

2025-01-07effective

4definitions

12/12/2024references

Sepsis Claim Coverage Criteria

Sepsis claim coverage criteria

Covered when ALL of the following documentation, coding, and sequencing requirements are met:

Claims are supported by documentation in the member's medical record and reviewed case-by-case for evidence of infection, evidence of end-organ dysfunction from a dysregulated host response, and a treatment course consistent with the type of infection

Provider documentation must note evidence of infection; negative or inconclusive blood cultures do not preclude sepsis coding when the provider documents clinical evidence (e.g., viremia or fungemia)

Organ dysfunction must be attributable to the dysregulated host response (sepsis) and generally should not be coded separately except as additional acute organ dysfunction codes when sequencing for septic shock

For cases meeting criteria for septic shock, sequence the systemic infection code first, then R65.21 (severe sepsis with septic shock) or T81.12 (postprocedural septic shock); additional acute organ dysfunction codes may be assigned; R65.2 subcategory codes cannot be assigned as the principal diagnosis

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySepsis coding and billing guidance

Policy CodePolicy CPCPO41

Change TypeNon-material operational updates

Effective DateJan 7, 2025

Next Review DateN/A

Key ActionSubmit requested supporting documentation promptly; ensure medical records and provider statements clearly document infection and organ dysfunction to support coded diagnoses.

SourceLink

On This Page

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ICD-10 Coding Guidance for Sepsis and Septic Shock

ICD-10 guidance for sepsis and septic shockICD-10Covered

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

Sequencing rule for septic shock

Sequencing ruleIn cases of septic shock, sequence the code for the systemic infection first, then assign R65.21 (severe sepsis with septic shock) or T81.12 (postprocedural septic shock); additional acute organ dysfunction codes may also be assigned.

Principal diagnosis restrictionCodes from subcategory R65.2 (severe sepsis) cannot be assigned as the principal diagnosis.

Organ dysfunction codingOrgan dysfunction is part of the sepsis definition and generally should not be coded separately except as additional acute organ dysfunction codes in septic shock per sequencing guidance.

Documentation Requests and Provider Responsibilities

Documentation Required

Documentation requests and provider responsibilities

The plan may request supporting documentation; providers must submit additional documentation upon request and ensure submitted documentation supports the diagnosis and coding billed. Providers are responsible for submitting accurate documentation of services performed and for using valid HIPAA code sets and industry-standard coding guidelines when submitting claims.

Submit any additional documentation upon request to support the diagnosis billed.
Ensure medical record documentation supports coding for infection and organ dysfunction as billed.
Use valid HIPAA code sets and follow industry coding guidelines (e.g., ICD-10-CM, CMS guidance).

Key Definitions

Sepsis

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

Clinical basisClaims are reviewed for evidence of infection and end-organ dysfunction triggered by a dysregulated host response, using Sepsis‑3 definitions.

Documentation requirementProvider documentation must note evidence of infection; negative or inconclusive blood cultures require provider statement of viremia/fungemia or other evidence.

Septic Shock

DefinitionSubset of sepsis with profound circulatory and cellular/metabolic abnormalities that substantially increase mortality.

Association with 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.

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

SIRS

DefinitionSystemic inflammatory response syndrome (SIRS).

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

Policy implicationDocumentation of SIRS alone does not meet coding criteria for sepsis—further evidence of infection and organ dysfunction is required.

MAP (Mean arterial pressure)

DefinitionMean arterial pressure (MAP).

ContextMAP is included among definitions used in applying Sepsis‑3 criteria for assessment of circulatory status.

Clinical relevanceMAP may be used to assess hypotension/hypoperfusion in septic shock evaluation.