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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyFlorida Blue Sepsis Policy Update Coverage | OpenP…
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    CurrentFlorida BluePolicy N/A

    Sepsis Policy

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    Governs Florida Blue's inpatient claim payment and coding review for diagnoses of sepsis, applying Sepsis-3 clinical criteria to validate inpatient sepsis coding and reimbursement for all lines of business and providers.

    Policy Summary
    PayerFlorida Blue
    PolicySepsis Policy
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateOct 17, 2024
    Last ReviewOct 9, 2025
    Next Review DateOct 9, 2025
    Key ActionClaims with a diagnosis of sepsis will be reviewed using Sepsis-3 criteria and medical records must support the conditions billed; clinicians/facilities should apply Sepsis-3 at discharge to determine reporting and billing of sepsis.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Sepsis-3clinical definition used for claims validation
    All linespolicy applies to
    Inpatientclaim type addressed
    Annuallast reviewed

    Sepsis Validation Criteria

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Validation criteria for inpatient sepsis claims

    Florida Blue will validate inpatient sepsis diagnoses and associated services by clinical evidence using the Sepsis-3 definition; claims lacking supporting clinical documentation may not be validated for sepsis.

    Sepsis diagnosis and any sepsis-related services submitted on an inpatient claim must be supported by clinical documentation in the medical record that meets Sepsis-3 criteria.

    ALL of the following

    • Sepsis is present when there is life-threatening organ dysfunction caused by a dysregulated host response to infection.
    • Organ dysfunction is identified as an acute change in total SOFA score greater than or equal to 2 points consequent to the infection (Sepsis-3).SOFA score change >= 2
    • SIRS, SEP-1, and qSOFA are not recognized as definitions of sepsis and will not be used to validate a sepsis diagnosis.
    Certified coders, licensed clinicians, and/or physicians will evaluate medical records and perform DRG validation to confirm clinical evidence supports the codes on the submitted claim.

    ALL of the following

    • At discharge, clinicians and facilities should apply Sepsis-3 criteria to determine if the patient's clinical course supports reporting and billing of sepsis.
    • If the medical record lacks clinical evidence or fails to meet Sepsis-3 criteria, the sepsis diagnosis and associated services may not be validated for payment.

    ALL of the following

    • Providers should reference up-to-date coding guidance prior to claim submission.

    • Coding determination

      • If sepsis did occur, code as a confirmed diagnosis (assign the appropriate code).
      • If terms such as 'impending' or 'threatened' are listed as subterms in the Alphabetic Index, assign the given subterm code.
      • If 'impending' or 'threatened' are not listed as subterms, code the existing underlying condition(s) and not the condition described as impending or threatened.

    ICD-10 Guidance and Diagnostic Thresholds

    ICD-10-CM coding guidanceICD-10
    ICD-10-CM guidanceFollow most up-to-date coding guidance; code confirmed sepsis if it occurred, assign given code if subterms listed; if it did not occur, reference the Alphabetic Index for 'impending' or 'threatened' subterms and assign if present; if subterms are not listed, code the underlying condition(s) and not the condition described as impending or threatened.
    Sepsis diagnostic threshold — Sepsis-3
    Diagnostic thresholdAcute change in total Sequential Organ Failure Assessment (SOFA) score ≥ 2 consequent to the infection (Sepsis-3)
    Purpose of thresholdIdentifies organ dysfunction caused by a dysregulated host response to infection to validate sepsis on inpatient claims
    Use in claims reviewFlorida Blue will use this SOFA change threshold when reviewing inpatient claims to confirm that clinical evidence supports a sepsis diagnosis

    Claims Review and Documentation Requirements

    Documentation Required

    Sepsis claims review — document medical evidence using Sepsis‑3

    Claims submitted with a diagnosis of sepsis will be reviewed using the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The medical record must support the conditions billed and the sepsis-related services; clinicians and facilities should apply Sepsis-3 at discharge to determine whether the patient's clinical course supports reporting and billing of sepsis.

    • Sepsis-3 (acute change in total SOFA score ≥ 2 consequent to infection) is the definition used for validation.
    • SIRS, SEP-1 and qSOFA are not recognized definitions for sepsis validation.
    • Certified coders, licensed clinicians and/or physicians will clinically evaluate medical records and perform DRG validation to confirm clinical evidence supports submitted codes.

    Key Terms

    Sepsis (Sepsis-3) definition
    Clinical definitionSepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection (Sepsis-3)
    Operational criterionOrgan dysfunction is identified as an acute change in total SOFA score ≥ 2 consequent to the infection
    Non-recognized definitionsSIRS, CMS SEP-1, and quick-SOFA (qSOFA) are not recognized by Florida Blue as definitions for validating sepsis
    Implementation noteFlorida Blue applies Sepsis-3 to clinically evaluate medical records and validate inpatient sepsis diagnoses and related services
    Policy Summary
    PayerFlorida Blue
    PolicySepsis Policy
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateOct 17, 2024
    Last ReviewOct 9, 2025
    Next Review DateOct 9, 2025
    Key ActionClaims with a diagnosis of sepsis will be reviewed using Sepsis-3 criteria and medical records must support the conditions billed; clinicians/facilities should apply Sepsis-3 at discharge to determine reporting and billing of sepsis.
    SourceLink
    On This Page
    Sepsis Validation CriteriaICD-10 Guidance and Diagnostic ThresholdsClaims Review and Documentation RequirementsKey Terms