The Enigma of Sepsis

Sepsis is one of the most (if not the most) challenging concepts in the International Classification of Diseases, 10^th Edition, Clinical Modification (ICD-10-CM), the Health Insurance Portability and Accountability Act (HIPAA)-sanctioned transaction set for reporting diagnoses in the United States.  

No one seems to agree on what exactly sepsis is, or its clinical indicators. Clinicians and the World Health Organization’s (WHO’s) ICD-11 label sepsis as “a dysregulated host response to infection resulting in organ dysfunction,” manifested by varying criteria for adults and children; however, payors apparently seem to ignore applicable clinical indicators to reduce a hospital’s reimbursement for a sepsis-related diagnosis-related group (DRG).  

ICD-10-CM and the Centers for Medicare & Medicaid Services (CMS), on the other hand, still use “Sepsis-2” terminology, whereby sepsis can exist without an organ dysfunction. To report the more updated “Sepsis-3” terminology in ICD-10-CM, the physician must explicitly document “severe sepsis,” an archaic terminology, and its associated organ dysfunctions.

This dissonance is so difficult to navigate that even the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is investigating the Centers for Disease Control and Prevention (CDC) and CMS’s role, as evidenced by the OIG 2024 Work Plan that is currently ongoing (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000841.asp).  

To the credit of the CDC, the agency did propose in 2019 to amend ICD-10-CM to fit Sepsis-3 terminology; however, because of vigorous opposition, no further action was taken.  https://archive.cdc.gov/www_cdc_gov/nchs/data/icd/SEPSIS_tabular_final_dp.pdf  and https://archive.cdc.gov/www_cdc_gov/nchs/data/icd/Third_International_Consensus_Definitions_Sepsis_Septic.pdf.  

What a challenge! How can all involved provide great sepsis care if providers and those governing diagnostic language can’t agree on its terminology and criteria?

On the June 16 Monitor Mondays broadcast, James S. Kennedy, MD, president of CDIMD near Nashville, reported on his recent conversations with the CDC National Center for Health Statistics that governs ICD-10-CM as to what is needed to amend the ICD-10-CM classification. The goal is to sync its sepsis terminology with ICD-11, the current “Sepsis-3”criteria for adults, and the recently announced “Phoenix” criteria for children, in follow-up to his proposal submitted last fall, available at NCHS Proposal for Sepsis – March CM meeting – 20241205.pdf.

Unfortunately, according to authoritative sources, Dr. Kennedy’s proposal will not be considered at the Fall ICD-10-CM/PCS Coordination and Maintenance Committee, since it did not meet the CDC’s protocol and requirements for new ICD-10-CM code proposals, available at https://www.cdc.gov/nchs/icd/icd-10-maintenance/proposals.html. 

Apparently, the CDC requires that any proposals for new ICD-10-CM codes be only be two pages long, and must demonstrate the following four elements to survive their rigorous assessment protocol:

• Clinical Congruence – Any proposed code must be supported by medical practice and literature, with clear definitions and clinical criteria;
• Statistical Soundness – The new code must be statistically supported in volume and impact;
• Integration into the Electronic Medical Record – The terminology in the new code must be easily integrated in the medical record; and
• Medical Informatics – The new code must have a positive impact with medical informatics.

In addition, Dr. Kennedy told me that the CDC perceives a barrier in that if they required an organ dysfunction to report sepsis, there would be no code to represent the continuum between a localized infection without systemic features (e.g., fever, tachycardia, mild organ dysfunctions) and the overt appearance of organ dysfunctions defined by Sepsis 3 (adults) and Phoenix (children) criteria.  

To address this, the CDC appeared amenable to a clinical concept outlining, which could be labeled “early sepsis,” “pre-sepsis,” “sepsis in evolution,” “impending sepsis,” or similar language.

However, according to Dr. Kennedy, the CDC appeared to be quite clear that any new proposal for the use of these terms must be accompanied by reasonably universal criteria – which, from Dr. Kennedy’s observation, does not currently exist.  

One option may involve using Sepsis-2 criteria outlined in 2003, available at https://journals.lww.com/ccmjournal/abstract/2003/04000/2001_sccm_esicm_accp_ats_sis_international_sepsis.38.aspx, whereby “the clinician goes to the bedside, identifies myriad symptoms, and regardless of an evident infection, declares the patient to ‘look septic.’”

Mervyn Singer, MD, the lead author of Sepsis 3, discussed other potential options involving artificial intelligence (AI) that may be of assistance in his Intensive Care Medicine article in December 2024: https://link.springer.com/article/10.1007/s00134-024-07694-z. 

More recent literature affirms this potential approach: https://journals.lww.com/ccejournal/fulltext/2025/06000/quantifying_healthcare_provider_perceptions_of_a.4.aspx.  

In addressing this challenge, a group of physicians, clinical documentation integrity (CDI) specialists, and health information management (HIM) professionals, including Dr. Kennedy, are preparing a new proposal for consideration at the Spring 2026 ICD-10-CM Coordination and Maintenance Committee meeting that will require the full support of credible clinical groups, such as the Society of Critical Care Medicine, the Sepsis Alliance, the American College of Physician Advisors (a sponsor of Monitor Monday), the American Medical Association, the American Academy of Pediatrics, the American College of Surgeons, and others, to succeed. 

Cooperation from other ICD-10-CM Cooperating Parties, including the American Hospital Association, CMS, and the American Health Information Management Association (AHIMA), is especially vital for success.

Programming note:

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