This document provides coding guidelines for Sepsis Outpatient and Inpatient Short Stays to ensure the patient status is appropriately billed based on the patient’s diagnoses and treatment performed.
Coding Guidelines
A Short Stay is a brief period of treatment or observation, typically lasting less than 48 to 72 hours.
Sepsis
Acute care hospitalizations for sepsis require accurate coding, supported by clear documentation from a qualified healthcare professional (QHP) and in accordance with ICD-10-CM Official Guidelines for Coding and Reporting. Therefore, these may be reviewed via pre- or post-pay review for reimbursement.
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 sepsis diagnosis, treatment, and any complications and comorbidities.
Claims with a sepsis diagnosis and status of a Short Stay will be denied when the stay is 0-1 days with the following parameters.
Discharge status of:
- Discharge to home or self-care (01)
- Discharged/transferred to home under care of organized home health service organization in anticipation of covered skills care (06)
- Left against medical advice or discontinued care (07)
Sepsis Diagnosis-related groups (DRGs):
- 870 — Septicemia or Severe Sepsis with Mechanical Ventilation (MV) >96 Hours or Peripheral Extracorporeal Membrane Oxygenation
- 871 — Septicemia or Severe Sepsis without Mechanical Ventilation (MV) > 96 hours with Major Complication/Comorbid Condition (MCC)
- 872 — Septicemia or Severe Sepsis without Mechanical Ventilation (MV) > 96 hours without Major Complication/Comorbid Condition (MCC)
Note: The mildest form of sepsis (DRG 872), would be more appropriate for an inpatient status.
Any sepsis DRG claim with a three day or less length of stay and the following discharge status codes will be reimbursed accordingly.
- Expired (20)
- Transferred to other inpatient facilities (multiple)
- Hospice (50)
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
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