Sepsis 2025: The Definition Dilemma

Background: Why Sepsis Still Challenges Us

Sepsis remains a leading cause of mortality, morbidity, and healthcare expenditure. Despite its ancient recognition, the medical community continues to grapple with a universally accepted clinical definition. In 2025, the prevailing standard is the Sepsis-3 definition, yet confusion and inconsistency in documentation persist, impacting both patient care and reimbursement.

 

Evolution of Sepsis Definitions

• Current Standard (2025): Sepsis-3 is used by CMS, Medicare Advantage plans, and the CDC.
• OIG Review: Retrospective audits of Medicare claims are using Sepsis-3 to assess overbilling.

What This Means for Documentation
To ensure clinical validity and defend the diagnosis of Sepsis under Sepsis-3, documentation must clearly demonstrate:

1. A Serious, Life-Threatening Condition

   • Describe the patient’s clinical picture as acutely ill, unstable, or deteriorating.

   • Use language that reflects the severity of illness (e.g., “critically ill,” “hemodynamically unstable”).

2. Timely and Appropriate Treatment

   • Document initiation of Sepsis bundles: IV fluids, antibiotics, vasopressors, lactate levels, blood cultures.

   • Reflect urgency and alignment with current Sepsis treatment protocols.

3. Explicit Link Between Infection and Organ Dysfunction

   • Clearly connect the dots: “Patient’s acute kidney injury is due to Sepsis from pneumonia.”

   • Avoid vague or isolated documentation of infection or organ dysfunction without causality.

⚠️ Note: Sepsis without documented Sepsis-induced organ dysfunction is not Sepsis under Sepsis-3.

 

Role of the Clinical Documentation Specialist (CDS)

The CDS is a key influencer in aligning provider documentation with the 2025 Sepsis definition. CDS can lead the transition with the following actions:

 

Action Steps for CDS:

• Educate providers on Sepsis-3 criteria and its implications for coding and reimbursement.
• Query proactively when documentation lacks clarity or fails to link infection to organ dysfunction.
• Collaborate with:
  • Physician Advisors to reinforce clinical alignment.
  • Chief Medical Officers to drive institutional messaging.
  • Coding Teams to ensure consistency between clinical and coded data.

Messaging to Providers:

• Sepsis = Infection + Organ Dysfunction caused by the infection.
• If there’s no organ dysfunction, it’s not Sepsis under Sepsis-3.
• Your documentation drives patient care, quality metrics, and reimbursement integrity.

Final Thoughts

The path to universal acceptance of Sepsis-3 requires a unified, consistent effort. Clinical Documentation Specialists are uniquely positioned to bridge the gap between clinical care and regulatory expectations. By championing accurate, complete, and Sepsis-3-aligned documentation, you help ensure patients receive appropriate care and institutions receive appropriate reimbursement.