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MP 10.01.11


Medical Policy


Original Policy Date

Created Status/Date
Created by consensus/4:2012


Return to Medical Policy Index 


Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


To ensure the appropriate ICD-9CM codes are being used for inpatient hospitalizations for the clinical diagnosis of Septicemia. It is noted that the average  mean length of stay for MS DRG 872 which is Septicemia or Severe Sepsis without mechanical ventilation and without major complication, is 5.2 days.


Sepsis and its consequences are challenging diagnoses both from a clinical documentation and  medical record coding perspective.  It is important for physicians  to use the proper clinical terminology (e.g. Bacteremia vs. Septicemia or Urosepsis vs. Sepsis) in their documentation.  Proper documentation of sepsis or its consequences in the medical records is important  to ensure accurate facility coding and billing.


Bacteremia is a laboratory finding of bacteria in the blood in the absence of two or more signs of sepsis.

Septicemia is the acute clinical illness associated with Bacteremia. It is an infectious disease due to accumulation and persistence of bacteria and/or toxins in the blood and marked by high fever, shaking chills, prostration and if untreated hypotension, shock and death.

SIRS (Systemic Inflammatory Response Syndrome) is the systemic response to infection, trauma/burns, or other  insult (such as cancer) with symptoms including fever, tachycardia, tachypnea and leukocytosis.

Sepsis  =  Underlying Infection + SIRS (2 or more clinical findings of SIRS not attributable to any other cause)

Sepsis Syndrome (Severe sepsis) = Sepsis + Tissue/Organ Hypoperfusion 

Septicemia and Sepsis are not synonymous

SIRS and Septicemia are not synonymous

Clinical Progression:

Bacteremia →  Septicemia        
Systemic Response:  Systemic  Inflammatory Response Syndrome (SIRS ) → Sepsis →  Sepsis Syndrome →  Septic Shock →  Multi-organ Dysfunction Syndrome

Blue Cross of Idaho Clinical Criteria Guidelines:

The clinical diagnosis of Septicemia should be confirmed upon discharge, not the clinical suspicion at the time of admission.There is a Persistence of 3 or more Clinical Signs or Symptoms as listed below; measured 2 times at least  4 hours apart:

  • Temperature > 100.4F (38C) or Temp < 97 (36C)
  • HR > 100
  • Hypotension (SBP< 100)
  • WBC > 12K or < 4K and/or > 10% bands
  • RR > 24/min; and/or  pCO2 (arterial) < 32mmHg

Evaluation Elements

  • Monitoring of vital signs every 4 hours; in particular blood pressure, temperature, pulse, respiratory rate and heart rate
  • Evaluation of mental status changes
  • Laboratory evaluation: blood and urine cultures, CBC with differential, chemistry

Treatment Elements

 Treatment of underlying infection with appropriate antibiotic, anti-fungal, and/or anti-viral.

 IV Fluids and/or medications which are being given to maintain hemodynamic stability.

 Supplemental oxygen is being given to maintain oxygenation.  


To ensure accurate facility coding of Septicemia  based upon Blue Cross of Idaho clinical guidelines.

Previously, facility billing for Sepsis, Septicemia, SIRS, Severe Sepsis or Septic Shock was  reviewed through post payment audit.  As of July 1, 2012, hospital charges  for the above diagnosis may be reviewed on a prepayment basis for accurate coding and documentation in the medical record. 

Policy History

Date Action Reason
04/03/12 Add to Administration section New policy

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