As inpatient costs rise, sepsis has been a topic of discussion among payers and payment integrity vendors.

Did you know that “the number of inpatient stays at the highest severity level increased almost 20% from 2014 to 2019 and accounted for nearly half of all Medicare spending on inpatient hospital visits”?1

To bring awareness and address this issue, the clinical staff at CGI got together to answer the following questions on sepsis reviews.

When reviewing a sepsis claim, what are the first three things you should look for?

The first three things you should look for when reviewing a sepsis claim are patient condition on presentation (includes assessment and diagnostic testing), what was done (implemented treatment plan), and re-evaluation of the patient after treatment.

What do we frequently see as errors?

We commonly see errors in sepsis-2 vs. sepsis-3, which have different clinical criteria. The signs and symptoms that the patient presents could be caused by any infection, such as a UTI. While an infection is present because it has not reached the stages of life-threatening organ dysfunction, it may not be detected and diagnosed accurately.

Did you know average recoveries on a sepsis audit are around $4,000 a claim, and we find recoveries on over 55% of the sepsis claims we review.

What (if any) are red flags to look for on a sepsis claim that’s under review?

A few criteria to look out for on a sepsis claims are short length of stay (<2 days) with a discharge status "01" (home), an extensive list of significant co-morbidities, and procedures performed or listed (COVID = remdesivir/C. Plasma, mechanical ventilation <96 hours).

Where are the mistakes being made – what do people forget to document?

Inaccurate documentation on the assessment evaluation and lack of implemented treatment plans are common mistakes found regarding claims. Based on a post-review of the medical record, providers assume they can recall what happened during the patient's stay. Additionally, medical record documentation contains several check-offs, carried over in progress notes daily that may have resolved or are no longer a concern versus writing pertinent facts and the treatment plan based on the current everyday assessment. We cannot assume what physicians denoted or add our thoughts of clarification to a situation if it is not documented. We only have the documentation to validate the conditions billed on the claim.

$57.47B estimated aggregate cost of sepsis hospital care for the entire U.S. population.2

What value does CGI bring to sepsis audits?

CGI provides feedback to our clients, leading to improved standards of clinical practice. Aspects of patient care are evaluated against the expected standard of care set by CMS. When/where necessary, changes are made to reflect accurate reporting and validation of the billed claim.

To learn more about sepsis and coding misalignment, read the Report on Medicare Compliance.


1OIG: Hospital stays getting more expensive for Medicare, raising upcoding concerns

2Sepsis Among Medicare Beneficiaries: 4. Precoronavirus Disease 2019 Update

Helpful websites for medical record review findings

UpTo Date 
US National Library of Medicine / National Institute of Health  
Merck Manuals/Professional