CurrentFidelis CarePolicy CC.PP.073

Payment Policy: Sepsis Diagnosis

Governs pre- and post-pay review and documentation requirements for inpatient facility claims for sepsis for adults (≥18) across all Fidelis Care products, specifying clinical criteria and coding considerations used to validate sepsis diagnoses for payment.

Policy Summary

PayerFidelis Care

PolicyPayment Policy: Sepsis Diagnosis

Policy CodePolicy CC.PP.073

Change TypeNo material changes

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 plan will request medical records and complete clinical validation within 60 days of receipt.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

SOFA ≥2SOFA threshold

≥18Applies to age

60 daysReview timeframe

>2 mmol/LLactate

>40%Septic shock mortality

Sepsis Coverage and Audit Criteria

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.

Sepsis reimbursement criteria and audit rules

Documentation and review criteria required to support sepsis diagnosis for reimbursement:

Physician or licensed independent practitioner must document diagnosis and supporting clinical information in the inpatient medical record

Organ dysfunction represented by an increase in SOFA score of 2 points or more from baseline (when baseline not provided, an imputed baseline will be determined using current records and the SOFA tool); SOFA points due to local infection are not counted toward systemic SOFA

Medical record should document treatment to address sepsis (examples: 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 procedure codes

Upon receipt of records, 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 medical interventions documented

If documentation does not support the billed diagnosis, the Health Plan will issue an audit determination letter and send explanation codes on the Explanation of Payment (EOP); providers may submit a dispute

Clinical validation review will be completed within 60 days from receipt of medical records

Policy scope: applies to inpatient facility claims for members/enrollees aged 18 and over

Coverage guidance and legal precedence

Policy guidance and precedence notes

This payment policy is a guide to payment and does not constitute a contract or guarantee regarding payment; coverage and payment determinations are subject to plan documents and applicable legal and regulatory requirements

Providers are expected to exercise professional medical judgment; this policy does not dictate clinical care and does not constitute medical advice

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

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

ICD-10 Codes and Clinical Thresholds

Example ICD-10 diagnosis codes referencedICD-10

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

ICD-10 coding updates referenced in revision historyICD-10

A41.54	Added diagnosis code to ICD-10 table (policy note)
T81.44XA	Code added previously to ICD-10 coding table (referenced in revision history)

inv-05: SOFA score threshold

SOFA increase thresholdIncrease in SOFA of 2 points or more from baseline to represent organ dysfunction supporting sepsis diagnosis

Baseline handlingBaseline SOFA may be imputed if not provided in the medical record

Clinical significanceSOFA increase of ≥2 is associated with in-hospital mortality >10% (per Sepsis-3 task force)

inv-06: Sepsis-3 clinical thresholds

Organ dysfunction (Sepsis-3)Organ dysfunction = increase in SOFA score ≥2 from baseline

Septic shock clinical criteriaSeptic shock = vasopressor requirement to maintain MAP ≥65 mmHg and serum lactate >2 mmol/L (>18 mg/dL) in absence of hypovolemia

Associated mortalitySeptic shock criteria identify patients with hospital mortality rates >40%

Provider Responsibilities and Claim Review Process

Documentation Required

Pre- and post-pay review; medical record requests

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 the medical record is received, certified professional coders and clinicians will clinically validate the documentation to ensure the diagnosis billed is supported by the clinical information and medical interventions documented. 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. If sepsis was diagnosed/billed in error, the Health Plan will issue an audit determination letter explaining the determination and providing details for submitting a dispute.

Medical record requests will be made when a potential billing error is identified
Clinical validation performed by certified coders and clinicians
Audit determination letter and dispute instructions provided when billing error found
Clinical validation completed within 60 days of receipt of records
Explanation codes sent on the Explanation of Payment (EOP)

Note

Claims and coverage governance

Providers must follow the terms, conditions, exclusions, and limitations of the member's plan document (for example, evidence of coverage, certificate of coverage, policy, or contract). Coverage and payment determinations under this payment policy are a guide to payment and are subject to plan-level contract language, state and federal requirements, and applicable administrative policies and procedures. This payment policy does not guarantee payment and does not replace the coverage rules in the member's plan documents. For Medicaid members, state Medicaid coverage provisions take precedence where they conflict with this policy.

Coverage and payment determinations subject to plan documents and regulatory requirements
Policy is a guide to payment and not a guarantee of coverage or payment
State Medicaid provisions override policy when in conflict

Note

Medicare consistency check

For Medicare members, review applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) prior to applying the criteria in this payment policy to ensure consistency with Medicare coverage rules. Refer to the CMS website (http://www.cms.gov) for the latest NCDs and LCDs and any related guidance.

Review all applicable NCDs and LCDs before applying this policy to Medicare members
Refer to CMS for current Medicare coverage determinations

Key Definitions

inv-10: Sepsis (per Sepsis-3)

Sepsis (Sepsis-3) definitionLife‑threatening organ dysfunction caused by a dysregulated host response to infection

DifferentiatorSepsis distinguished from other infections by presence of organ dysfunction and an abnormal/dysregulated host response

Clinical implicationSepsis should be considered in any serious presenting infection due to high mortality if unrecognized/untreated

inv-11: SOFA score

SOFA tool descriptionSequential Organ Failure Assessment (SOFA) with component scores for respiration, coagulation (platelets), liver (bilirubin), cardiovascular (MAP and vasopressors), CNS (GCS), and renal (creatinine/urine output)

Cardiovascular componentScore 0 = MAP ≥70 mm Hg; higher scores based on MAP <70 mm Hg or increasing vasopressor dosing

Respiratory and renal componentsRespiration scored by PaO2/FiO2 thresholds; renal scored by creatinine or urine output ranges

inv-12: Sepsis (Sepsis-3)

Operational sepsis definitionSepsis (operational): organ dysfunction represented by an increase in SOFA score of two points or more from baseline

Use in auditPolicy aligns sepsis diagnosis validation with Sepsis‑3 operational criteria for reimbursement review

Outcome linkageSOFA ≥2 threshold associated with >10% in‑hospital mortality

inv-13: Septic shock (Sepsis-3)

Septic shock definition (Sepsis-3)Septic shock: sepsis with vasopressor requirement to maintain MAP ≥65 mm Hg and serum lactate >2 mmol/L (>18 mg/dL) in absence of hypovolemia

Physiologic basisRepresents profound circulatory, cellular, and metabolic abnormalities with greater mortality risk than sepsis alone

Association with mortalityThis combination of vasopressor need and lactate >2 mmol/L is associated with hospital mortality rates >40%