Clinical Validation for Sepsis when payer uses Sepsis-3

My memory might be incorrect, but I have always been under the impression (not sure if said to me or read) that a hospital is only to have one Sepsis criteria used to clinically validate the diagnosis. In the event the criteria is not present, or not clearly linked to the Sepsis, regardless of payer, a clinical validation query is warranted. Whether the internal Sepsis criteria is Sepsis-2, Sepsis-3, or an internal home grown criteria. Is this correct? If so, does anyone know who/what governing body set that guidance?

Asking because so many payers use Sepsis-3 and if hospital utilizes Sepsis-2, how do they ever help insulate the diagnosis from a denial?


  • I don't have an answer to whom set this guidance, but I too have the issue of denials with payers that use Sepsis 3 criteria while my organization uses Sepsis 2.

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