CurrentCommunity Health Plan WashingtonPolicy CC.PP.073

Payment Policy: Sepsis Diagnosis

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Governs inpatient facility reimbursement reviews for sepsis diagnoses for adult members (≥18) across all product types, describing documentation requirements and pre-/post-pay audit processes.

Policy Summary

PayerCommunity Health Plan Washington

PolicyPayment Policy: Sepsis Diagnosis

Policy CodePolicy CC.PP.073

Change TypeNo material changes

Effective Date

Last ReviewNov 1, 2025

Next Review DateNov 20, 2025

Key ActionWhen a sepsis diagnosis is billed the plan may perform a pre- or post-pay review and request medical records to validate the diagnosis; an audit determination letter will follow.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥2SOFA threshold

≥18Member age

60 daysRecord review timeframe

>40% mortalitySeptic shock criteria

03/01/2022–11/25Revision history

Sepsis Documentation & Audit Criteria

inv-01: Sepsis documentation and audit criteria

Documentation and clinical criteria used to validate sepsis diagnosis for reimbursement:

Physician or licensed independent practitioner must document the diagnosis and supporting clinical information in the inpatient medical record (e.g., interventions such as blood cultures, antibiotics, and fluid management).

Sepsis is operationalized per Sepsis-3 as life-threatening organ dysfunction caused by a dysregulated host response to infection; organ dysfunction is represented by an increase in SOFA score of two points or more from the member/enrollee's baseline.

When baseline SOFA score is not provided, the current medical record and the SOFA tool will be used to determine an imputed baseline SOFA score representing the member/enrollee's condition prior to the acute infection coded as sepsis.

SOFA points attributable to local infection alone will not be counted toward the systemic SOFA score for sepsis diagnosis.

SIRS, CMS SEP-1, and qSOFA are not recognized as sepsis definitions and will not be used to validate a sepsis diagnosis.

Documentation should demonstrate treatment to address sepsis, including blood cultures, antibiotics, and fluid management to maintain mean arterial pressure > 70 mmHg.

Claims with a sepsis diagnosis are subject to pre- or post-pay review; when a potential billing error is identified the Health Plan will request medical records to validate the diagnosis and procedures billed.

Once records are received, certified professional coders and clinicians will clinically validate that: (a) the medical record contains the necessary information and (b) the diagnosis billed is supported by the clinical information and interventions documented.

After review the Health Plan will issue an audit determination letter and send Explanation of Payment codes; clinical validation review will be completed within 60 days from receipt of medical records.

inv-02: Precedence and applicability notes

General coverage and precedence notes

For Medicaid members/enrollees, state Medicaid coverage provisions take precedence over this payment policy when conflicts exist; refer to the state Medicaid manual for applicable provisions.

For Medicare members/enrollees, applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed prior to applying this payment policy's criteria.

This payment policy is a guide to payment and does not constitute a contract, guarantee of payment, or medical advice; coverage and payment determinations are subject to plan coverage documents, state and federal requirements, and applicable administrative policies and procedures.

Health Plan retains the right to change, amend, or withdraw this payment policy; legal and regulatory requirements govern in the event of any discrepancy with the policy's effective date.

inv-03: Provider responsibilities

Provider conduct, documentation expectations, and policy limitations

Providers are expected to exercise professional medical judgment in providing care; this payment policy does not dictate how providers should practice medicine or recommend specific treatments.

Providers are independent contractors and are solely responsible for the medical advice and treatment of members/enrollees; they are not agents or employees of the Health Plan.

Coverage and payment determinations are subject to the terms, conditions, exclusions, and limitations of the applicable coverage documents and to state and federal requirements; providers should consult plan documents for specific coverage guidance.

ICD-10 and DRG Coding References

ICD-10 sepsis and related codes (examples listed)ICD-10

A41.9	Sepsis, unspecified organism
R65.21	Severe sepsis with septic shock
R65.20	Severe sepsis without septic shock
T81.44XA	Sepsis following a procedure, initial encounter

DRG groupings referencedmixed

870-872

DRG descriptors related to septicemia/severe sepsis

ICD-10 codes referenced in revision historyICD-10

A41.54	Diagnosis code added to ICD-10 table per revision history
T81.44XA	Code added earlier (referenced in revision history)

inv-07: SOFA increase threshold — key clinical threshold

SOFA increase thresholdIncrease of 2 or more points from baseline (SOFA Δ ≥2)

Imputed baseline when not documentedWhen baseline SOFA not provided, current records and SOFA tool will be used to determine an imputed baseline representing pre-infection status

Exclusion of local infection pointsSOFA points attributable to local (non-systemic) infection are not counted toward systemic SOFA for sepsis diagnosis

inv-08: SOFA score change threshold — operational threshold for sepsis

Operational sepsis thresholdSepsis operationalized as increase in SOFA score ≥2 points from baseline (SOFA Δ ≥2)

Associated mortality noteAn increase in SOFA score ≥2 is associated with in-hospital mortality >10% (per Sepsis-3 task force)

Use in audit/validationSOFA Δ ≥2 is the clinical metric used by the health plan to validate sepsis diagnoses during pre- or post-pay review

inv-09: Septic shock physiologic thresholds

Septic shock physiologic criteriaRequirement for vasopressor(s) to maintain mean arterial pressure ≥65 mm Hg AND serum lactate >2 mmol/L (in absence of hypovolemia)

Prognostic associationThis combination of vasopressor requirement and lactate >2 mmol/L is associated with hospital mortality >40%

Subset of sepsisSeptic shock is defined as a subset of sepsis with more profound circulatory, cellular, and metabolic abnormalities

Audit, Record Requests & Provider Responsibilities

Documentation Required

Audit and medical record requests for sepsis claims

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 records are received, certified professional coders and clinicians will clinically validate the documentation to ensure the medical record contains the necessary information and the diagnosis billed is supported by the clinical information and interventions. The health plan will issue an audit determination letter with explanation codes on the Explanation of Payment (EOP); the clinical validation review will be completed within 60 days from receipt of medical records.

Medical records will be requested when a potential billing error is identified (pre- or post-pay reviews).
Certified coders and clinicians will validate documentation and interventions against the billed diagnosis.
Audit determination letters and EOP explanation codes will be provided; review completed within 60 days of record receipt.

Note

Provider professional judgment and limits of the policy

Providers must exercise professional medical judgment; this payment policy is a guide to payment and does not dictate medical care. Coverage and payment determinations are subject to the terms, conditions, exclusions and limitations of the coverage documents and to state and federal requirements.

Providers are independent contractors and are solely responsible for medical advice and treatment.
This policy does not constitute a contract, guarantee of payment, or medical advice.

Key Definitions and Operational Criteria

inv-12: Sepsis (per Sepsis-3) — definition and operationalization (increase in SOFA score ≥2)

Sepsis (Sepsis-3) definitionLife‑threatening organ dysfunction caused by a dysregulated host response to infection; operationalized as an increase in SOFA score of 2 or more from baseline

Clinical differentiationSepsis is differentiated from other infections by the presence of organ dysfunction and an abnormal/dysregulated host response

Consideration in evaluationSepsis should be considered in any serious presenting infection due to overlapping presentations with other conditions

inv-13: Diagnosis Related Groups (DRG) — definition and role in hospital case mix and payment

DRG definitionDiagnosis Related Groups (DRG) are a patient classification scheme that relates hospital case mix to costs incurred by the hospital

Case mix componentsCase mix includes severity of illness, prognosis, treatment difficulty, need for intervention, and resource intensity

Role in paymentDRGs are used to classify inpatient services for prospective payment systems; Medicare payments for inpatient services are based on predetermined amounts tied to DRG classification

inv-14: Sepsis (operational definition) — sepsis-related organ dysfunction represented by increase in SOFA score

Operational definition of sepsis-related organ dysfunctionSepsis-related organ dysfunction is represented by an increase in the Sequential Organ Failure Assessment (SOFA) score of two points or more from baseline

Use for clinical validationThe health plan uses SOFA Δ ≥2 to validate sepsis on inpatient claims during medical record review

Imputation guidanceIf baseline SOFA is not documented, the plan will impute baseline using current records and the SOFA tool

inv-15: Septic shock (operational definition) — vasopressor requirement to maintain MAP ≥65 mm Hg and elevated lactate

Septic shock operational definitionSeptic shock is a subset of sepsis identified by vasopressor requirement to maintain MAP ≥65 mm Hg and serum lactate >2 mmol/L in the absence of hypovolemia

Clinical implicationThis definition identifies patients with particularly profound circulatory, cellular, and metabolic abnormalities and higher mortality risk

Audit relevanceMeeting septic shock criteria supports coding of septic shock and may affect DRG assignment and payment validation

Policy Revision Timeline

2022-03-01policy_created

Policy developed and reviewed by specialist.

2022-08-30administrative_update

Removed a broken link in the policy.

2023-03-31annual_review_table_update

Annual review with updates to Table 1 (Bilirubin, Cardiovascular, Creatinine scoring changes), wording replacements for clarity, and references updated.

2023-10-23coding_and_formatting_update

Updated Table 1 formatting for clarity, updated DRG descriptions, and added code T81.44XA to the ICD-10 coding table; references reviewed and updated.

2024-01-24coding_update

Added diagnosis code A41.54 to the ICD-10 table.

2024-06-13annual_review

Conducted annual review, confirmed codes, and updated policy.

2024-09-24annual_review

Annual review with references reviewed and updated; reviewed by external specialist.

2024-09-25annual_review

Annual review with references reviewed and updated; reviewed codes and descriptions.

2024-11-25clarification_updateLatest

Clarified SOFA score calculation to specify it is calculated from the member/enrollee's baseline, changed reviewers from 'registered nurses' to 'clinicians' under reimbursement guidelines, and made minor wording clarifications.

Policy Summary

PayerCommunity Health Plan Washington

PolicyPayment Policy: Sepsis Diagnosis

Policy CodePolicy CC.PP.073

Change TypeNo material changes

Effective Date

Last ReviewNov 1, 2025

Next Review DateNov 20, 2025

Key ActionWhen a sepsis diagnosis is billed the plan may perform a pre- or post-pay review and request medical records to validate the diagnosis; an audit determination letter will follow.

SourceLink

On This Page

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Payment Policy: Sepsis Diagnosis

Customize your policy alerts

Sign up for Community Health Plan Washington Policy CC.PP.073 alerts

Get alerted when Policy CC.PP.073 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs inpatient facility reimbursement reviews for sepsis diagnoses for adult members (≥18) across all product types, describing documentation requirements and pre-/post-pay audit processes.

Sepsis Documentation & Audit Criteria

inv-01: Sepsis documentation and audit criteria

Documentation and clinical criteria used to validate sepsis diagnosis for reimbursement:

SOFA points attributable to local infection alone will not be counted toward the systemic SOFA score for sepsis diagnosis.

SIRS, CMS SEP-1, and qSOFA are not recognized as sepsis definitions and will not be used to validate a sepsis diagnosis.

Documentation should demonstrate treatment to address sepsis, including blood cultures, antibiotics, and fluid management to maintain mean arterial pressure > 70 mmHg.

inv-02: Precedence and applicability notes

General coverage and precedence notes

For Medicaid members/enrollees, state Medicaid coverage provisions take precedence over this payment policy when conflicts exist; refer to the state Medicaid manual for applicable provisions.

Health Plan retains the right to change, amend, or withdraw this payment policy; legal and regulatory requirements govern in the event of any discrepancy with the policy's effective date.

inv-03: Provider responsibilities

Provider conduct, documentation expectations, and policy limitations

Providers are expected to exercise professional medical judgment in providing care; this payment policy does not dictate how providers should practice medicine or recommend specific treatments.

Providers are independent contractors and are solely responsible for the medical advice and treatment of members/enrollees; they are not agents or employees of the Health Plan.

ICD-10 and DRG Coding References

ICD-10 sepsis and related codes (examples listed)ICD-10

A41.9	Sepsis, unspecified organism
R65.21	Severe sepsis with septic shock
R65.20	Severe sepsis without septic shock
T81.44XA	Sepsis following a procedure, initial encounter

DRG groupings referencedmixed

870-872

DRG descriptors related to septicemia/severe sepsis

ICD-10 codes referenced in revision historyICD-10

A41.54	Diagnosis code added to ICD-10 table per revision history
T81.44XA	Code added earlier (referenced in revision history)

inv-07: SOFA increase threshold — key clinical threshold

SOFA increase thresholdIncrease of 2 or more points from baseline (SOFA Δ ≥2)

Imputed baseline when not documentedWhen baseline SOFA not provided, current records and SOFA tool will be used to determine an imputed baseline representing pre-infection status

Exclusion of local infection pointsSOFA points attributable to local (non-systemic) infection are not counted toward systemic SOFA for sepsis diagnosis

inv-08: SOFA score change threshold — operational threshold for sepsis

Operational sepsis thresholdSepsis operationalized as increase in SOFA score ≥2 points from baseline (SOFA Δ ≥2)

Associated mortality noteAn increase in SOFA score ≥2 is associated with in-hospital mortality >10% (per Sepsis-3 task force)

Use in audit/validationSOFA Δ ≥2 is the clinical metric used by the health plan to validate sepsis diagnoses during pre- or post-pay review

inv-09: Septic shock physiologic thresholds

Septic shock physiologic criteriaRequirement for vasopressor(s) to maintain mean arterial pressure ≥65 mm Hg AND serum lactate >2 mmol/L (in absence of hypovolemia)

Prognostic associationThis combination of vasopressor requirement and lactate >2 mmol/L is associated with hospital mortality >40%

Subset of sepsisSeptic shock is defined as a subset of sepsis with more profound circulatory, cellular, and metabolic abnormalities

Audit, Record Requests & Provider Responsibilities

Documentation Required

Audit and medical record requests for sepsis claims

Medical records will be requested when a potential billing error is identified (pre- or post-pay reviews).
Certified coders and clinicians will validate documentation and interventions against the billed diagnosis.
Audit determination letters and EOP explanation codes will be provided; review completed within 60 days of record receipt.

Note

Provider professional judgment and limits of the policy

Providers are independent contractors and are solely responsible for medical advice and treatment.
This policy does not constitute a contract, guarantee of payment, or medical advice.