News: UnitedHealthcare to use Sepsis-3 criteria for pre-pay reviews

CDI Strategies - Volume 15, Issue 19

UnitedHealthcare has announced that, effective July 1, 2021, Medicare Advantage and commercial claims for sepsis-related treatment may be reviewed on a pre-payment or post payment basis. Claims will be reviewed using UnitedHealthcare’s Sepsis Clinical Guidelines, including use of Sepsis-3 criteria.

UnitedHealthcare states that these reviews “promote accurate diagnosis and treatment of sepsis and help ensure the claim is coded and billed at the appropriate treatment level.” The agency notes that they are using Sepsis-3 criteria as it is “the most recent evidence-based definition of sepsis and supports the International Guidelines for Management of Sepsis and Septic Shock 2016.”

UnitedHealthcare says there’s no change to the clinical guideline itself other than a change in the review timing. If it cannot validate the presence of sepsis, the claim may be denied or adjusted, and a denial letter provided.

Sepsis continues to be one of the most common conditions sparking physician queries for CDI professionals. It causes nearly 300,000 deaths annually, and its conflicting clinical criteria, confusing coding instructions, and convoluted CMS regulations (the agency currently uses Sepsis 2 criteria for ICD-10-CM code assignment and some) quality measures make capturing sepsis documentation critical.

Editor’s note: The UnitedHealthcare announcement can be found here.

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