To help ensure compliance with the coding and billing of services submitted with a diagnosis of sepsis, we review clinical information, including lab results, treatment and medical management, in the medical records submitted.  In order to conduct the review accurately and consistently, our review process for sepsis diagnoses applies coding and documentation guidelines, in addition to the updated and most recent sepsis 3 clinical criteria, published in JAMA February 2016.  Clinicians and facilities should apply the sepsis 3 criteria when determining at discharge if their patient’s clinical course supports the coding and billing of a sepsis diagnosis. The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the sepsis 3 definition and criteria.

Featured In:
June 2019 Anthem New Hampshire Provider Newsletter