Sepsis Policy
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Governance of billing, coding, and claim review practices for sepsis-related services and treatments for Blue Cross Blue Shield of Oklahoma members and contracted providers.
No material clinical or coverage changes in this revision.
Sepsis Coverage and Review Criteria
Sepsis coverage and coding criteria
Claims are reviewed for clinical documentation supporting sepsis diagnosis, organ dysfunction, and treatment consistent with the type of infection present. The Plan may request supporting documentation; documentation submitted must support the diagnosis billed.
Septic shock documentation (ANY of the following must be met for septic shock coding):
- Clinical evidence of circulatory failure associated with severe sepsis (hypoperfusion and/or persistent hypotension).
- Requires vasopressors to maintain mean arterial pressure (MAP) > 65 mm Hg despite adequate volume resuscitation.
- Serum lactate level > 2 mmol/L despite adequate volume resuscitation.
Sequencing, Codes, and Clinical Thresholds
| R65.21 | Severe sepsis with septic shock (referenced as code that follows infection code when sequencing septic shock) |
| T81.12 | Referenced as an alternate code to follow systemic infection code in septic shock cases |
Documentation Requests, Responsibilities, and DRG Review
Documentation requests and provider responsibilities
The Plan may request supporting documentation to substantiate billed diagnoses; providers must submit accurate documentation of services performed and are urged to provide any additional records when requested. Documentation submitted must support the diagnosis billed, and failure to adhere to billing and coding policies may impact claims processing and reimbursement.
- Submit accurate documentation of services performed and coding using valid code sets (ICD-10-CM, CPT, etc.).
- Provide additional supporting records upon request to substantiate the diagnosis and services billed.
DRG validation review for sepsis-related codes
Diagnosis-related group (DRG) codes associated with sepsis may prompt a validation review of the submitted principal and secondary diagnoses, which can affect DRG assignment and claims processing.
- Claims with DRG codes related to sepsis are subject to validation review of principal and secondary diagnoses.
- Accurate documentation and appropriate sequencing of infection and organ dysfunction codes are required to support DRG assignment.
Key Definitions and Coding Rules
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