AdministrativeCommercialMedicare AdvantageJune 12, 2024

Phoenix Sepsis Criteria for coding and billing pediatric sepsis

To ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis for our pediatric members, we review clinical information (including treatment and medical management) and laboratory and diagnostic procedure findings in the medical records submitted for review. To conduct the review accurately and consistently, our review process for pediatric sepsis applies coding and documentation guidelines.

Beginning with admission dates of July 1, 2024, and later for members aged 29 days through 17 years of age, we will also apply the updated and most recent publication of the Society of Critical Care Medicine Pediatric Sepsis Definition Task Force criteria known as the Phoenix Sepsis Criteria, published in the Journal of the American Medical Association (JAMA) in January 2024.

Clinicians and facilities should apply the Phoenix Sepsis Criteria when determining at discharge if the pediatric patient’s clinical course supports the coding and billing of a diagnosis of sepsis. The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the Phoenix Sepsis Criteria.

Together, we can work towards improved outcomes.

jamanetwork.com/journals/jama/article-abstract/2814297

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PUBLICATIONS: July 2024 Provider Newsletter