CurrentWellCarePolicy CC.PP.073

Payment Policy: Sepsis Diagnosis

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This policy governs coding validation and reimbursement review processes for inpatient facility claims with a sepsis diagnosis for WellCare members across all product types (adult inpatient encounters). It describes documentation requirements, clinical criteria used to validate sepsis, and pre- and post-pay audit practices.

Policy Summary

PayerWellCare

PolicyPayment Policy: Sepsis Diagnosis

Policy CodePolicy CC.PP.073

Change TypeNo material change

Effective Date

Next Review Date

Key ActionClaims with a sepsis diagnosis will be reviewed on either a pre- or post-pay basis and the Health Plan will request medical records when a potential billing error is identified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysclinical validation review timeframe from receipt of medical records

SOFA ≥ 2SOFA score threshold indicating organ dysfunction for sepsis

All productsproduct types to which policy applies

OwnershipPolicy is property of Centene Corporation

Coverage criteria for Sepsis diagnosis coding

Coverage criteria for sepsis diagnosis coding

Documentation by a physician or licensed independent practitioner in the inpatient medical record must support sepsis diagnoses for reimbursement. Covered when ALL of the following are met:

Physician or licensed independent practitioner documentation in the inpatient medical record must reflect the criteria to support a sepsis diagnosis, including documentation of treatments provided (e.g., blood cultures, antibiotics, fluid management to maintain mean arterial pressure).

Clinical operationalization of sepsis consistent with Sepsis-3: life-threatening organ dysfunction caused by a dysregulated host response to infection.

Evidence of organ dysfunction demonstrated by an increase in SOFA score of two points or more from baseline.

When baseline SOFA is not provided, the imputed baseline will be determined using current medical records and the SOFA tool.

SOFA scoring operational detail: SOFA points attributable to local infection are excluded from the systemic SOFA score used to validate sepsis.

Medical record must contain necessary clinical information and interventions to support the diagnosis billed on the claim; certified professional coders and registered nurses will clinically validate documentation upon receipt of records.

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 and will issue an audit determination letter with dispute instructions if sepsis is determined to be billed in error.

Clinical validation review timeframe: the review will be completed within at least 60 days from receipt of medical records.

Coding guidance and updates

ICD-10 diagnosis examples referencedICD-10

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

Noted ICD-10 coding updateICD-10

T81.44XA

ICD-10 code added to ICD-10 coding table (document mentions addition)

SOFA score change — threshold increase of 2 points or more

SOFA change thresholdIncrease of 2 points or more from baseline (SOFA ≥ 2) used to represent organ dysfunction for sepsis validation.

When baseline missingIf baseline SOFA is not provided, current medical records and the SOFA tool will be used to determine an imputed baseline for comparison.

Associated mortality noteAn increase in SOFA score ≥2 is associated with an in-hospital mortality greater than 10% (per Sepsis‑3 recommendations).

Provider actions, reviews, and regulatory considerations

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 medical records are requested, certified professional coders and registered nurses will clinically validate the documentation to ensure the medical record contains the necessary information and that the diagnosis and procedures billed are supported by the clinical information, including medical interventions. If a billing error or unsupported diagnosis is identified, the Health Plan will issue an audit determination letter to the provider describing the determination and dispute instructions. Clinical validation reviews 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 sepsis diagnosis may be reviewed pre- or post-pay
Medical records requested for validation; certified coders and RNs will review
Audit determination letter and dispute instructions issued to provider when sepsis was diagnosed/billed in error
Clinical validation completed within 60 days of receipt of records
EOP explanation codes issued at conclusion of review

Billing Rule

Explanation of Payment codes and outcomes

Example Explanation of Payment (EOP) codes and outcomes that may be used at the conclusion of sepsis reviews include both denial and pay outcomes. Examples (not all-inclusive) include: CPI02 — Denied after review: Incomplete Medical Records Received; CPI05 — Medical Records not Received; CPI07 — DENIED: Diagnosis not supported; CPI10 — DENIED: Incorrect sequencing of diagnosis codes; CPI11 — DENIED: Incorrect discharge status submitted; CPI13 — DENIED: Incorrect principal diagnosis; CPI14 — DENIED: Incorrect principal procedure; CPI16 — DENIED: Missing medical records; CPI17 — DENIED: Principal Diagnosis Inappropriately Coded; CPI18 — DENIED: Procedure Inappropriately Coded; CPI22 — DENIED: Documentation does not support services billed; CPI23 — DENIED: Duplicate services billed; CPI27 — DENIED: Incorrect billing of date of service; CPI28 — DENIED: Incorrect records submitted for review; CPI29 — DENIED: Information requested was not received from provider; CPI30 — DENIED: Information requested not received from the patient; CPI36 — DENIED: Unbundled procedure code; CPI42 — DENIED: Incorrect place of service; CPI60 — Incorrect provider address; IA — DENY: MEDICAL RECORDS NOT RECEIVED PER PREVIOUS REQUEST; IB — PAY: DRG PAYMENT INCREASE AFTER REVIEW OF MEDICAL RECORDS; IC — PAY: DRG PAYMENT ADJUSTMENT AFTER REVIEW OF MEDICAL RECORDS; IF — PAY: REINSTATE PAYMENT AFTER REVIEW OF MEDICAL RECORDS; OI / QD / QF — PEND or PAY outcomes for DRG validation/audit as applicable.

Denial examples: CPI02, CPI05, CPI07, CPI10, CPI11, CPI13, CPI14, CPI16, CPI17, CPI18, CPI22, CPI23, CPI27, CPI28, CPI29, CPI30, CPI36, CPI42, CPI60, IA
Pay/adjustment examples: IB, IC, IF, QF
Pend/audit examples: OI, QD — Medical records required for DRG validation audit

Note

Regulatory and effective-date considerations

Providers must review and apply applicable CMS national coverage determinations (NCDs), local coverage determinations (LCDs), and any state Medicaid/Medicare provisions when using this policy. This payment policy is effective as of the date determined by the Health Plan; the posting date may not be the effective date. If there is a discrepancy between this policy's effective date and legal or regulatory requirements, law and regulation govern. The Health Plan may change, amend, or withdraw this payment policy at any time. This policy does not constitute medical advice or a guarantee of payment; providers remain responsible for exercising professional judgment and for complying with all plan-level coverage documents, state and federal requirements, and contractual terms.

Review applicable CMS NCDs and LCDs (cms.gov) when applying this policy
Comply with state Medicaid/Medicare provisions and plan-level coverage documents
Policy effective date is set by the Health Plan; legal/regulatory requirements supersede if discrepant
Health Plan may amend or withdraw this policy at any time
Policy is guidance only — providers retain responsibility for clinical judgment and documentation

Key definitions

Sepsis — definition

DefinitionLife‑threatening organ dysfunction caused by a dysregulated host response to infection; organ dysfunction can be represented by an increase in SOFA score of two or more from baseline.

Clinical considerationSepsis should be considered in any serious presenting infection because it may present similarly to many other conditions and is a leading cause of death if unrecognized and untreated.

Operational sourcePolicy aligns with the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis‑3) for clinical operationalization.

Septic shock — definition and clinical identifiers

DefinitionSeptic shock is a subset of sepsis with profound circulatory, cellular, and metabolic abnormalities associated with greater mortality than sepsis alone.

Clinical identifiersClinical identification requires vasopressor requirement to maintain mean arterial pressure (MAP) ≥ 65 mm Hg and serum lactate > 2 mmol/L in the absence of hypovolemia.

Mortality contextThis combination of vasopressor requirement and elevated lactate is associated with hospital mortality rates greater than 40% (Sepsis‑3).

Non‑recognized sepsis definitions

Non‑recognized definitionsSystemic inflammatory response syndrome (SIRS) is not recognized as a definition of sepsis and will not be used to validate sepsis diagnosis.

SEP‑1 not usedThe CMS Severe Sepsis and Septic Shock Management Bundle (SEP‑1) is not recognized for validation and will not be used to validate sepsis diagnosis.

qSOFA not usedQuick‑SOFA (qSOFA) is not recognized as a definition of sepsis and will not be used to validate sepsis diagnosis.

Health Plan — definition

Health Plan definition"Health Plan" means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan's affiliates, as applicable.

Policy purposeThis payment policy provides guidance to assist in making coverage and payment determinations and administering benefits; it does not constitute a contract or guarantee of payment.

Effective date and changesThe payment policy is effective as determined by the Health Plan and may be changed, amended, or withdrawn; legal and regulatory requirements govern if discrepancies exist.

Policy Summary

PayerWellCare

PolicyPayment Policy: Sepsis Diagnosis

Policy CodePolicy CC.PP.073

Change TypeNo material change

Effective Date

Next Review Date

Key ActionClaims with a sepsis diagnosis will be reviewed on either a pre- or post-pay basis and the Health Plan will request medical records when a potential billing error is identified.

SourceLink

On This Page

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Payment Policy: Sepsis Diagnosis

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Coverage criteria for Sepsis diagnosis coding

Coverage criteria for sepsis diagnosis coding

Documentation by a physician or licensed independent practitioner in the inpatient medical record must support sepsis diagnoses for reimbursement. Covered when ALL of the following are met:

Clinical operationalization of sepsis consistent with Sepsis-3: life-threatening organ dysfunction caused by a dysregulated host response to infection.

Evidence of organ dysfunction demonstrated by an increase in SOFA score of two points or more from baseline.

When baseline SOFA is not provided, the imputed baseline will be determined using current medical records and the SOFA tool.

SOFA scoring operational detail: SOFA points attributable to local infection are excluded from the systemic SOFA score used to validate sepsis.

Clinical validation review timeframe: the review will be completed within at least 60 days from receipt of medical records.

Coding guidance and updates

ICD-10 diagnosis examples referencedICD-10

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

Noted ICD-10 coding updateICD-10

T81.44XA

ICD-10 code added to ICD-10 coding table (document mentions addition)

SOFA score change — threshold increase of 2 points or more

SOFA change thresholdIncrease of 2 points or more from baseline (SOFA ≥ 2) used to represent organ dysfunction for sepsis validation.

When baseline missingIf baseline SOFA is not provided, current medical records and the SOFA tool will be used to determine an imputed baseline for comparison.

Associated mortality noteAn increase in SOFA score ≥2 is associated with an in-hospital mortality greater than 10% (per Sepsis‑3 recommendations).

Provider actions, reviews, and regulatory considerations

Documentation Required

Pre- and post-pay review and record request

Claims with sepsis diagnosis may be reviewed pre- or post-pay
Medical records requested for validation; certified coders and RNs will review
Audit determination letter and dispute instructions issued to provider when sepsis was diagnosed/billed in error
Clinical validation completed within 60 days of receipt of records
EOP explanation codes issued at conclusion of review

Billing Rule

Explanation of Payment codes and outcomes

Denial examples: CPI02, CPI05, CPI07, CPI10, CPI11, CPI13, CPI14, CPI16, CPI17, CPI18, CPI22, CPI23, CPI27, CPI28, CPI29, CPI30, CPI36, CPI42, CPI60, IA
Pay/adjustment examples: IB, IC, IF, QF
Pend/audit examples: OI, QD — Medical records required for DRG validation audit

Note

Regulatory and effective-date considerations

Review applicable CMS NCDs and LCDs (cms.gov) when applying this policy
Comply with state Medicaid/Medicare provisions and plan-level coverage documents
Policy effective date is set by the Health Plan; legal/regulatory requirements supersede if discrepant
Health Plan may amend or withdraw this policy at any time
Policy is guidance only — providers retain responsibility for clinical judgment and documentation

Key definitions

Sepsis — definition

DefinitionLife‑threatening organ dysfunction caused by a dysregulated host response to infection; organ dysfunction can be represented by an increase in SOFA score of two or more from baseline.

Operational sourcePolicy aligns with the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis‑3) for clinical operationalization.

Septic shock — definition and clinical identifiers

DefinitionSeptic shock is a subset of sepsis with profound circulatory, cellular, and metabolic abnormalities associated with greater mortality than sepsis alone.

Clinical identifiersClinical identification requires vasopressor requirement to maintain mean arterial pressure (MAP) ≥ 65 mm Hg and serum lactate > 2 mmol/L in the absence of hypovolemia.

Mortality contextThis combination of vasopressor requirement and elevated lactate is associated with hospital mortality rates greater than 40% (Sepsis‑3).

Non‑recognized sepsis definitions

Non‑recognized definitionsSystemic inflammatory response syndrome (SIRS) is not recognized as a definition of sepsis and will not be used to validate sepsis diagnosis.

SEP‑1 not usedThe CMS Severe Sepsis and Septic Shock Management Bundle (SEP‑1) is not recognized for validation and will not be used to validate sepsis diagnosis.

qSOFA not usedQuick‑SOFA (qSOFA) is not recognized as a definition of sepsis and will not be used to validate sepsis diagnosis.

Health Plan — definition

Policy purposeThis payment policy provides guidance to assist in making coverage and payment determinations and administering benefits; it does not constitute a contract or guarantee of payment.

Effective date and changesThe payment policy is effective as determined by the Health Plan and may be changed, amended, or withdrawn; legal and regulatory requirements govern if discrepancies exist.