News: Cigna adopts Sepsis-3 criteria for claims validation
Cigna announced in its first quarter 2020 Network News that it will be adopting Sepsis-3 criteria. The news item says that the change will take place immediately and it’s “part of [their] effort to promote the accurate diagnosis and treatment of sepsis, and use the appropriate billing and coding.”
Cigna says that if, after reviewing the adult patient record and according to the Sepsis-3 criteria, they feel that sepsis was not a valid diagnosis and not present, the DRG claim will be adjusted accordingly. The claim will reflect the revised DRG, as supported by the documentation.
The announcement defines Sepsis-3 as a “life-threatening organ dysfunction caused by a dysregulated host response to infection,” and it says that it “is the most recent evidence-based definition available.”
They note that Sepsis-3
- Is based on updated evidence-based medicine
- Supports the Surviving Sepsis Campaign International Guidelines
- Is endorsed by 31 medical societies
- Provides the most clinically relevant definition of sepsis with a Sequential Organ Failure Assessment (SOFA) score of two or more (which is associated with an in-hospital mortality >10 percent) as an adjunct in clinical diagnosis of sepsis (meaning that SOFA is not part of the sepsis definition, but it assists the provider in making the diagnosis)
This news makes Cigna the second major private payer to officially adopt the sepsis-3 criteria. UnitedHealthcare was the first to do so in October of 2018.
Editor’s note: The Cigna announcement can be found here. To read about UnitedHealthcare’s embrace of Sepsis-3, click here.