We’ll begin editing, recoveries on sepsis short-stay claims

Blue Cross Blue Shield of Michigan is implementing a new payment policy in November 2024 for the payment of inpatient claims with a diagnosis of sepsis.

Based on medical literature, sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Patients are likely to have a prolonged hospital or ICU stay.
Inpatient admissions with a diagnosis of sepsis and billed with the following diagnosis-related group codes with a length of stay of three days or less and a discharge status of “home” or “skilled nursing facility” will be denied.

• DRG 870 — Septicemia or Severe Sepsis with Mechanical Ventilation (MV) >96 Hours or Peripheral Extracorporeal Membrane Oxygenation 
• DRG 871 — Septicemia or Severe Sepsis without Mechanical Ventilation (MV) > 96 hours with Major Complication/Comorbid Condition (MCC)

In addition, if a claim was previously paid for either DRG 870 or 871 with a length of stay of three days or less and a discharge status of “home” or “skilled nursing facility,” we’ll adjust the claim to deny and take back reimbursement previously made to the health care provider.

In instances where we deny a claim or recover reimbursement, the provider will be able to rebill with a more appropriate DRG, such as dehydration, urinary tract infection or other diagnosis that more accurately reflects the patient’s condition.

We’ll accept a sepsis diagnosis resulting in an inpatient stay of three days or less with an appropriate discharge status code for patients who expire or are transferred to other facilities or hospice.