Here’s our sepsis DRG reimbursement policy

Effective Nov. 1, 2024, Blue Cross Blue Shield of Michigan implemented a sepsis diagnosis-related group, or DRG, reimbursement process for inpatient claims billed with certain sepsis DRGs for all lines of business.

Inpatient admissions that are billed using the following DRGs with a length of stay of three days or less and a discharge status of home (01) or skilled nursing facility (03) may 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)

According to the Centers for Medicare & Medicaid Services, the geometric mean length of stay, or GMLOS, for sepsis Medicare severity diagnosis-related groups, or MS-DRGs, 870 and 871 are 13.5 days and 5.1 days, respectively; DRG 872, for the mildest form of sepsis, is 3.6 days.

Considerations

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 (01) or skilled nursing facility (03), the claim may be adjusted to deny. Any reimbursement previously made to the health care provider may be recovered.

If the health plan either denied a claim or recovered 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.

Exclusions

The mildest form of sepsis, listed as DRG 872, isn’t subject to this policy secondary to its shorter average 3.6-day length of stay:

• DRG 872 — Septicemia or Severe Sepsis without Mechanical Ventilation (MV) > 96 hours without Major Complication/Comorbid Condition (MCC)

Any sepsis DRG claim with a three day or less length of stay and the following discharge status codes will be reimbursed accordingly:

• Expired (20)
• Leave against medical advice (07)
• Transferred to other inpatient facilities (multiple)
• Hospice (50)

Any sepsis DRG inpatient hospital claim with a three day or less length of stay and an associated observation level of care will be reimbursed at the billed DRG.