Loading...Loading...Policy No: 120
Originally Created: 07/01/2025
Section: Facility
Last Reviewed:
Last Revised:
Approved: 03/13/2025
Effective: 07/01/2025
Policy Applies To: Commercial Participating and Non-Participating Providers & Medicare Advantage Participating Providers
This policy applies to inpatient facilities.
Organ dysfunction – Impaired or abnormal functioning of one or more organs or organ systems, resulting in a failure to perform their normal physiological functions.
Quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) – A score for detection of patients at risk of sepsis outside of intensive care units.
Rapid Treatment – Initiation of labs, parenteral antibiotics, and resuscitative fluids within three (3) hours of identification of sepsis.
Sepsis – Life-threatening organ dysfunction caused by a dysregulated host response to infection.
Sequential (Sepsis-related) Organ Failure Assessment (SOFA) – A score to assess the acute morbidity of critical illness at a population level and has been widely validated as a tool for this purpose across a range of healthcare settings and environments.
This policy addresses adults, defined as age 18 and older.
Acute care hospitalizations for sepsis require accurate coding, supported by clear documentation from a qualified healthcare professional and in accordance with ICD-10-CM Official Guidelines for Coding and Reporting. This policy ensures correct coding through pre- and post-pay review for reimbursement.
Sepsis Documentation Requirements for Correct Coding and Billing
Providers are expected to meet the Sepsis-3 criteria, which is based on the SOFA score. The SOFA score can be found in the JAMA Sepsis-3 article.
- Organ dysfunction is identified as an acute change in total SOFA score > 2 points related to the infection.
- When baseline SOFA score is not provided, current medical records and the SOFA tool will be used to determine the imputed baseline SOFA score prior to acute infection coded as sepsis.
- Physician must explicitly link organ dysfunction to sepsis or infection.
- SOFA points due to local infection will not be counted toward the systemic SOFA score for sepsis diagnosis.
Providers must maintain clear and consistent documentation to support sepsis diagnosis and treatment with:
- Rapid treatment and frequent reassessment
- Regular progress notes detailing diagnosis, treatment and management
- A discharge summary accurately reflecting diagnosis, treatment, and any complications and comorbidities.
Providers are expected to use the most current coding sources. Sepsis and septic shock coding guidelines are available in the ICD-10-CM Official Guidelines for Coding and Reporting. If the Sepsis criteria is not met, the sepsis diagnosis will not be considered when determining claim reimbursement. DRG reimbursement would follow guidelines published in reimbursement policy for Facility DRG Validation but would not consider the sepsis diagnosis.
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
Sepsis syndromes in adults: epidemiology, definitions, clinical presentation, diagnosis, and prognosis
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.