CurrentCommunity Health Plan WashingtonPolicy CC.PP.073

Payment Policy: Sepsis Diagnosis

Governance of pre- and post-pay review, documentation requirements, and coding guidance for inpatient sepsis diagnoses for adult members (≥18) across all product types.

Policy Summary

PayerCommunity Health Plan Washington

PolicyPayment Policy: Sepsis Diagnosis

Policy CodePolicy CC.PP.073

Change TypeNo material change

Effective Date

Next Review DateNov 20, 2025

Key ActionClaims with a sepsis diagnosis will be reviewed on either a pre- or post-pay basis and the Health Plan may request medical records to validate the billed diagnosis and procedure codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18age of members covered

SOFA ≥2SOFA increase threshold

MAP ≥65 + lactate>2Septic shock criteria

60 daysrecord review timeframe

R65.20, R65.21, A41.*ICD-10 examples

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Sepsis Documentation and Review Criteria

Sepsis documentation and review criteria

Requirements and validation process for inpatient sepsis diagnosis coding for reimbursement:

Documentation must be by a physician or licensed independent practitioner in the inpatient hospital medical record and be consistent with current guidelines (Sepsis-3).

Sepsis is defined per Sepsis-3 as life‑threatening organ dysfunction caused by a dysregulated host response to infection; organ dysfunction can be represented by an increase in SOFA score of two points or more from baseline.

When baseline SOFA is not provided, the current medical record and the SOFA tool will be used to determine an imputed baseline; SOFA points due to local infection are excluded from the systemic SOFA score for sepsis diagnosis.

Clinical documentation must include treatment to address sepsis, for example 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 diagnosis and procedure codes billed on the claim.

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

The clinical validation review will be completed within 60 days from receipt of medical records; if sepsis was diagnosed/billed in error, the Health Plan will issue an audit determination letter and provide instructions for dispute; explanation codes will be sent on the Explanation of Payment.

Policy application and precedence

General coverage guardrails and precedence statements

This payment policy provides guidance to assist in coverage and payment determinations but does not constitute a contract or guarantee of payment; coverage is subject to plan documents, state and federal requirements, and applicable plan‑level administrative policies and procedures.

Health Plan retains the right to change, amend, or withdraw this payment policy; if there is a discrepancy between the policy effective date and applicable legal or regulatory requirements, law and regulation govern.

For Medicaid members, state Medicaid coverage provisions take precedence when they conflict with this payment policy; refer to the state Medicaid manual for relevant provisions.

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

SIRS, SEP‑1, and qSOFA are not recognized as definitions of sepsis for purposes of validating sepsis diagnosis and will not be used to validate sepsis diagnosis.

ICD-10, DRG, and SOFA Guidance

Selected ICD-10 codes referencedICD-10

R65.20	Severe sepsis without septic shock
R65.21	Severe sepsis with septic shock
A41.9	Sepsis, unspecified organism

DRG descriptors and related numeric DRG rangesmixed

870-872

Septicemia or severe sepsis DRG descriptors referenced (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)

ICD-10 updates referenced in revision historyICD-10

A41.54	Sepsis due to Acinetobacter baumannii (added to ICD-10 table per revision history entry 01/24)
T81.44XA	Sepsis following a procedure, initial encounter (added to ICD-10 coding table per revision history entry 10/23)

inv-06: SOFA score increase threshold

ThresholdIncrease in SOFA score of 2 points or more from baseline

ContextUsed for clinical operationalization of sepsis for reimbursement and audit purposes

Source guidanceThird International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

inv-07: SOFA score change

DefinitionIncrease of 2 points or more from baseline indicates organ dysfunction for sepsis (Sepsis-3)

Associated riskLinked with in-hospital mortality greater than 10%

Operational useRepresents organ dysfunction for documentation and coding validation

inv-08: Septic shock lab/vitals threshold

Septic shock criteriaVasopressor requirement to maintain MAP ≥65 mm Hg AND serum lactate >2 mmol/L in the absence of hypovolemia

Associated mortalityThis combination is associated with hospital mortality rates greater than 40%

Clinical identificationMeant to identify patients with particularly profound circulatory, cellular, and metabolic abnormalities

Audit, Record Requests, and Payment Determinations

Documentation Required

Pre- and post-pay review and record request

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 medical records are received, certified professional coders and clinicians will clinically validate the documentation to ensure the medical record contains the necessary information and that the diagnosis billed on the claim is supported by the clinical information, including medical interventions. The clinical validation review will be completed within 60 days from receipt of medical records. Explanation codes will be sent to the provider on the Explanation of Payment (EOP) at the conclusion of the review.

Claims with a sepsis diagnosis are subject to pre- or post-pay review.
Medical record requests will be made when a potential billing error is identified.
Clinical validation performed by certified coders and clinicians.
Review completed within 60 days of receipt of records; explanation codes provided on EOP.

Denial Risk

Audit determination and appeals

After review of the medical record, the Health Plan will issue an audit determination letter to the provider if sepsis was diagnosed or billed in error. The letter will provide a thorough explanation of the determination and will include instructions for submitting a dispute. Providers may dispute an audit determination following the instructions in the determination letter. Example explanation codes that may be used on the EOP include (not all-inclusive): CPI01 (Denied after review: Incomplete Medical Records Rcvd), CPI02 (Medical Records not Received), CPI05 (DENIED: Diagnosis not supported), CPI07 (DENIED: Incorrect sequencing of diagnosis codes), CPI11 (DENIED: Incorrect DRG assignment), CPI22 (DENIED: Documentation does not support services billed), and others.

Audit determination letter with explanation and dispute instructions will be issued to provider when error found.
Providers should follow the dispute process described in the audit determination letter to appeal.
Common EOP explanation codes may include CPI01, CPI02, CPI05, CPI07, CPI11, CPI22, CPI23, CPI27, CPI36, iA, iB, iC.

Note

Payment determination guidance

This payment policy provides guidance to assist in payment determinations but does not guarantee payment. Coverage and payment determinations are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and to applicable state and federal laws and plan-level administrative policies and procedures. For Medicaid members/enrollees, state Medicaid coverage provisions take precedence when they conflict with this policy; consult the state Medicaid manual. For Medicare members/enrollees, applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed prior to applying this policy. The Health Plan retains the right to change, amend, or withdraw this payment policy.

Policy is a guide to payment and not a contract or guarantee of payment.
State Medicaid provisions override this policy where conflicts exist.
Review applicable Medicare NCDs/LCDs before applying this policy.

Key Terms and Definitions

inv-13: Sepsis

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

Distinguishing featureAn abnormal or dysregulated host response plus presence of organ dysfunction differentiates sepsis from other infections

Clinical implicationPrimary cause of death from infection when not recognized and treated promptly

inv-14: Diagnosis Related Groups (DRG)

DefinitionPatient classification scheme relating the type of patients a hospital treats (case mix) to the costs incurred by the hospital

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

UseUsed to relate patient types to hospital costs (DRG grouping)

inv-15: Inpatient Prospective Payment System

DefinitionReimbursement method in which payments are based on a predetermined, fixed amount

ExampleFor inpatient services, payment amounts are based on classification such as DRGs

PurposeStandardizes Medicare payments for specified services

inv-16: Organ dysfunction (Sepsis-3)

RepresentationOrgan dysfunction is represented by an increase in the SOFA score of two points or more from baseline

Mortality associationThis SOFA change is associated with in-hospital mortality greater than 10%

Role in policyUsed to support sepsis diagnosis for documentation and reimbursement reviews

inv-17: Septic shock (Sepsis-3)

DefinitionSubset of sepsis with vasopressor requirement to maintain MAP ≥65 mm Hg and serum lactate >2 mmol/L (absence of hypovolemia)

Associated mortalityAssociated with hospital mortality rates greater than 40%

Clinical featuresIndicates particularly profound circulatory, cellular, and metabolic abnormalities