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October 2019

Medicare Plus Blue PPO audits to use Sepsis-3 criteria

HMS® began auditing Medicare Plus BlueSM reimbursed diagnosis-related group claims for clinical and coding validation in September, as announced in the September Record. HMS is an independent company working for Blue Cross Blue Shield of Michigan.

The audits will review medical records to ensure that:

  • Claims were billed in accordance with coding guidelines
  • Diagnoses were supported by documentation in the medical record.

Regarding a sepsis diagnosis, Blue Cross will use Sepsis-3 as the evaluation criteria for payment purposes. Sepsis-3 is the most recent evidence-based definition of sepsis, defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection.

Learn more about Sepsis-3 criteria by reviewing the article titled Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3),** published in JAMA.

Be ready to share medical charts for review during an audit. After an audit, HMS will send the findings and information on how you can ask for an appeal, if necessary.

If you have questions during an audit, call 1-866-875-1749 to speak with an HMS representative.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.
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