Provider Update: Sepsis Clinical Alignment & Improvement Project

AmeriHealth Caritas Ohio is committed to partnering with our providers to improve outcomes for members at risk for, or experiencing, sepsis. We have identified variation in the clinical diagnosis and documentation of sepsis, including cases where sepsis is coded but may not meet established clinical criteria. To support consistency and quality of care, AmeriHealth Caritas Ohio is aligning with national standards (Sepsis-3: Singer et al., JAMA 2016).

 

What this means for providers

• Use Sepsis-3 criteria to guide clinical diagnosis and documentation of sepsis
• Ensure documentation clearly supports the presence of sepsis and related treatment

Opportunity to partner

AmeriHealth Caritas Ohio has launched a Sepsis Improvement Project, focused on:

• Preventing sepsis when possible
• Improving early identification and treatment
• Reducing avoidable variation in care

Call to action

Providers interested in participating in our Sepsis Improvement Project can contact Provider Services via email OhioProviderServices@amerihealthcaritasoh.com.

Provider Update: Coming Soon - New Sepsis Reimbursement Policy

Soon AmeriHealth Caritas Ohio will be implementing a new Sepsis Reimbursement Policy (Core Sepsis) to ensure alignment between clinical documentation and reimbursement.

 

Key policy details

• Select sepsis DRGs/APR-DRGs will be subject to prepayment clinical validation using Sepsis-3 criteria.
• Medical record review will confirm:
  • Sepsis was present
  • Services rendered were clinically appropriate
• Payment may be adjusted if documentation does not support a sepsis diagnosis under Sepsis-3.

Important documentation requirements

• Documentation must clearly support a Sepsis-3–aligned diagnosis
• The following cannot be used alone to support a sepsis diagnosis:
  • System Inflammatory Response Syndrome (SIRS) criteria
  • Severe Sepsis and Septic Shock: Early Management Bundle (SEP-1) criteria
  • Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) scores
• Inpatient stays with length of stay ≤ 3 days, and discharge to home (01) or SNF (03) may be subject to non-reimbursement when documentation does not support sepsis.

Call to action

• Review clinical documentation practices to ensure alignment with Sepsis-3 criteria.
• Educate coding, CDI, and clinical teams on updated expectations.
• Ensure records clearly demonstrate clinical indicators, diagnosis rationale, and treatment.
• Providers with clarifying questions can contact Provider Services via email OhioProviderServices@amerihealthcaritasoh.com.