CurrentEmblemHealthPolicy N/A

Sepsis Coding Criteria (Payment Integrity Administrative Policy)

This policy governs pre- and post-payment reviews of Commercial, Medicare Advantage and Medicaid claims for sepsis-related treatment to validate that sepsis was present and that claims are coded and billed at the appropriate level; it affects hospitals and providers submitting such claims to EmblemHealth and its delegates.

Policy Summary

PayerEmblemHealth

PolicySepsis Coding Criteria (Payment Integrity Administrative Policy)

Policy CodePolicy N/A

Change TypeAdministrative/template updates (no material changes)

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit medical records promptly when you receive a request or electronic remittance to avoid claim delays or denials.

SourceLink

POLICY UPDATE CHANGES

Transferred policy content to individual company-branded template; no changes to policy title or policy number.

Policy created in 11/2021.

Commercial, Medicare & MedicaidLines of business covered

Pre- or post-paymentReview timing

Sepsis 2 or 3Guidelines referenced

2021 Int'l GuidelinesEvidence base

11/18/2025Most recent revision

Sepsis review and coding criteria

Claims for sepsis-related treatment may be reviewed to validate that sepsis was present using current sepsis definitions and clinical documentation.

Reviews may occur on a pre-payment or post-payment basis to validate sepsis-related claims and ensure appropriate coding and billing.

Review standard: use Sepsis 2 or Sepsis 3 guidelines as applicable by state law; the plan supports the International Guidelines for Management of Sepsis and Septic Shock 2021.

Documentation requirement: clinical documentation must clearly support that sepsis is confirmed; initiation of a sepsis protocol or diagnostic workup alone is insufficient to justify coding sepsis.

ALL of the following

If sepsis cannot be validated:

Policy Summary

PayerEmblemHealth

PolicySepsis Coding Criteria (Payment Integrity Administrative Policy)

Policy CodePolicy N/A

Change TypeAdministrative/template updates (no material changes)

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit medical records promptly when you receive a request or electronic remittance to avoid claim delays or denials.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding guidance and documentation standards

Sepsis coding guidancemixedCovered

Sepsis should be coded only when clinical documentation clearly supports sepsis is confirmed; coding should not be used when sepsis/SIRS is being ruled out or explained by another diagnosis.

Documentation standard

Documentation requirementClinical documentation must clearly support that sepsis is confirmed; initiation of a sepsis protocol or diagnostic workup alone is insufficient.

Coding exclusionDo not code sepsis when sepsis/SIRS is being ruled out or when signs are explained by another infection/diagnosis.

Claim re-coding rationaleMeeting sepsis protocol criteria for treatment does not automatically justify coding sepsis without supporting documentation.

Medical record requests and claim correction process

Documentation Required

Medical record request and submission

You will receive a letter from the plan, one of our delegate vendors, or an electronic remittance advice (ERA) indicating that medical records are required. Submit the requested medical records promptly — either by mail or through the electronic submission method specified in the request — to avoid delays in claim processing. Providing complete, timely documentation helps prevent unnecessary denials or extended review time.

Requests may arrive as a mailed letter or as an electronic remittance denial/ERA.
Submit records promptly using the method specified in the request to avoid processing delays.
Include all relevant documentation (history, exam, labs, cultures, progress notes, discharge summary) that supports the sepsis diagnosis and care provided.

Denial Risk

Potential denial and corrected claim process

If the plan cannot validate that sepsis was present or that billed services meet policy criteria, services may be denied, down-coded, or adjusted. In such cases the hospital may submit a corrected claim with appropriate diagnosis, procedure, or supporting documentation. You will receive a written explanation of the review outcome and information about any dispute or appeal rights.

Services may be denied, adjusted, or re-coded if documentation does not support the billed sepsis diagnosis or related services.
Hospitals may submit corrected claims when documentation supports a different code or to supply missing information.
Appeal or dispute rights will be provided in the outcome letter when applicable.

OpenPayer

Sepsis Coding Criteria (Payment Integrity Administrative Policy)

Sepsis review and coding criteria

Coding guidance and documentation standards

Medical record requests and claim correction process

Sepsis definitions