Updated on: October 22, 2013

Understanding Sepsis: An Example of the Convergence of Clinical Quality, Coding, Reimbursement and Audit

By Rayellen Kishbach
Original story posted on: October 21, 2013

The convergence of a number of Centers for Medicare & Medicaid Services (CMS) initiatives is intended to improve healthcare quality and therefore will impact all healthcare clinicians significantly, but these initiatives also will result in workflow changes for the coding and reimbursement professionals who support clinicians. Specifically, CMS is driving the meaningful use of electronic health records (EHR), quality reporting, third-party audits and the adoption of ICD-10; these efforts are meant to better ensure proper payments while improving patient safety, quality of care, and efficiency of care for Medicare beneficiaries. 

As an example, this article examines a specific and important clinical issue, sepsis, with a 360-degree review that touches on quality reporting, ICD-10 coding and reimbursement factors to consider.



Sepsis and septicemia should be a clinical area of significant focus across your organization because of the health consequences of these life-threatening conditions. Sepsis is a clinical syndrome that complicates severe infection, specifically characterized by the cardinal signs of inflammation (vasodilation, leukocyte accumulation, increased microvascular permeability) occurring in tissues that are remote from the infection. The National Institutes of Health (NIH) reports that:

“Every year, severe sepsis strikes about 750,000 Americans. It’s been estimated that between 28 and 50 percent of these people die — far more than the number of U.S. deaths from prostate cancer, breast cancer and AIDS combined.”[i]

And this has translated to an international effort to understand, prevent and treat sepsis. According to the Surviving Sepsis Campaign:

 “Severe sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, killing one in four (and often more), and increasing in incidence.” [ii]

Clinical Monitoring for Sepsis

A comprehensive discussion of the diagnostic criteria for sepsis is outside of the scope of this article, but the NIH and SSC guidelines indicate that detection of sepsis involves monitoring for key symptoms, including fever, hypotension, heart rate and edema, with diagnoses confirmed via blood tests and chest X-ray. With the adoption of electronic health records, someday it may become possible for hospitals to monitor for evidence of a developing infection automatically and in real time.

Sepsis Quality Measures

CMS includes monitoring and reporting for sepsis and septicemia as part of several quality initiatives, including the 30-day, risk-standardized readmission and complication inpatient hospital measures – and the all-cause unplanned readmission measure for 30 days post-discharge, for long-term care hospitals.

Quality reporting is often driven by coding, so it is important to understand how the quality measures actually translate to coding so sepsis patients can be identified.

Coding for sepsis involves also coding the underlying infectious agent. The Specifications Manual for National Hospital Inpatient Quality Measures includes the following ICD-9-CM codes as indicators of sepsis:

And the preview ICD-10-CM list includes those codes that general equivalency mappings (GEMs) map from the ICD-9-CM list:

Version 4.3:  Appendix P - Preview Section

These ICD-10-CM codes typically include the “code first” instructions to include the associated condition, such as:

  • Code first any associated: post-procedural streptococcal sepsis (T81.4)
  • Code first any associated: streptococcal sepsis during labor (O75.3)
  • Code first any associated: streptococcal sepsis following abortion or ectopic or molar pregnancy (O03-O07, O08.0)
  • Code first any associated: streptococcal sepsis following immunization (T88.0)
  • Code first any associated: streptococcal sepsis following infusion, transfusion or therapeutic injection (T80.2-)

It is important to note that there are additional ICD-10-CM codes that include the term “sepsis,” but are not presently included in the preview version of Table 3.2. These include the following:


Salmonella sepsis


Anthrax sepsis


Acute and fulminating melioidosis (Melioidosis sepsis)


Erysipelothrix sepsis


Disseminated mycobacterium avium-intracellulare complex (DMAC) MAC sepsis


Listerial sepsis


Gonococcal sepsis


Candidal sepsis


Puerperal sepsis


Severe sepsis without septic shock


Severe sepsis with septic shock

ICD-10 to MS-DRG Grouping for Sepsis Diagnosis codes

When looking at the impact of switching from ICD-9 to ICD-10, the reason for a MS-DRG change could be a complicating diagnosis. In this situation, specificity is key to driving proper assignment to the appropriate level while taking into account the CC/MCC designation of the secondary diagnoses. Often, CMS includes specified codes in the CC/MCC list, while the unspecified codes aren’t considered CC/MCCs. In the case of sepsis, most codes are designated as major complications/comorbidities (MCC), except for ICD-10 codes A24.1 and A31.2, which are CCs. This means that improper documentation and coding of sepsis as a complicating diagnosis can result in significant payment differences.

Another factor to consider is whether sepsis is the principal or secondary diagnosis. Under ICD-10, there are four grouping scenarios that can play out when there is a principal sepsis diagnosis:

  • Most sepsis codes group to MDC 18, MS-DRGs 870-872, Septicemia or severe sepsis.
  • Two sepsis codes group to MDC 18, MS-DRGs 867-869, Other infectious & parasitic diseases.
  • OB patients with puerperal sepsis group to MDC 14, MS-DRG 776, Postpartum & Post Abortion Diagnoses w/o O.R. Procedure (or similar if a procedure is involved).
  • HIV patients with sepsis group to MDC 25, MS-DRGs 974-976, HIV with Major Related Condition.

MS-DRG Reimbursement for Sepsis under ICD-10

It should be a goal for every organization to strive for proper payments; however, underpayments are still possible even when coding is correct. The quote below is taken from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report titled Medicare Compliance Review of Tampa General Hospital for Calendar Years 2008 through 2010:

“For 1 of 92 sampled inpatient claims, the hospital submitted the claim to Medicare with an incorrect diagnosis code, which resulted in an incorrect DRG. Specifically, the incorrectly coded claim generated DRG code 314 (Other Circulatory System Diagnoses with MCC) based on the principal diagnosis code of 999.31 (Infection Central Venous Catheter). However, the medical records supported a more severe diagnosis code as the cause of admission. The appropriate coding would have resulted in DRG code 870 (Septicemia or Severe Sepsis w/ Mechanical Ventilation 96+ hours) based on the secondary diagnosis of code 038.8 (Septicemia).

The hospital stated that the coding error occurred because the coder did not correctly identify the principal diagnosis supported by the documentation. As a result of this error, the hospital received an underpayment of $5,693.”

When sepsis is the principal diagnosis for admission, most of the sepsis diagnoses codes group to the three MS-DRGs for sepsis (870-872). Note the wide payment spread below, which clearly demonstrates that concise documentation is required to reflect additional related complications and comorbidities that will drive code assignment (and hence, payment) for an inpatient stay. 

There are two ICD-10-CM sepsis diagnosis codes that don’t group to the main sepsis MS-DRGs:

  • A24.1       Acute and fulminating melioidosis (Melioidosis sepsis)
  • A31.2       Disseminated mycobacterium avium-intracellulare complex (DMAC) MAC sepsis

These two codes group to an infection MS-DRG set instead, where payment is significantly less than for the sepsis DRGs.

Sepsis as a principal diagnosis for patients with HIV group to MS-DRGs 974-6:

And finally, obstetrics patients admitted specifically for puerperal sepsis (O85) group to MS-DRG 776, Postpartum & Post Abortion Diagnoses w/o O.R. Procedure.


Clearly, from a clinical perspective, early detection and response to sepsis infections is critical. From a business perspective, a detailed understanding of the coding specificity and claims practices surrounding this important issue is required to ensure both compliance with quality reporting and the proper reimbursement.

 About the Author

Rayellen Kishbach is the product development manager for coding  and reimbursement subscription products at MediRegs/Wolters Kluwer Law & Business. In this role, Rayellen works directly with clients, support, sales and development to create the best-in-class coding, compliance and reimbursement resources. She translates complex Medicare logic into easy to use tools and educational experiences that help thousands of health care professionals do their jobs more efficiently and accurately.

Contact the Author


Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis, Up-To-Date. http://www.uptodate.com/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis.

[ii] NIH Sepsis Fact Sheet. http://www.nigms.nih.gov/Education/factsheet_sepsis.htm.

[ii] Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. http://www.sccm.org/Documents/SSC-Guidelines.pdf.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.