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The sepsis coding landscape just shifted dramatically, and most healthcare organizations don't realize what's coming! Welcome back to Saturday Morning Tea and today we're connecting the critical dots between FY 2026 ICD-10-CM sepsis guidelines and the bombshell policy announcement from Horizon Blue Cross Blue Shield.
This isn't just about understanding coding guidelines - it's about seeing exactly how major payers will enforce those guidelines starting January 1, 2026. Horizon's new sepsis validation criteria using Sepsis-3 definitions signals a seismic shift in how sepsis claims will be reviewed, challenged, and potentially denied.
We'll walk through the official coding requirements for sepsis, severe sepsis, and septic shock, then show you exactly how Horizon plans to validate these diagnoses in real-world post-service reviews. From SIRS criteria limitations to infection documentation requirements, we're covering everything you need to protect your organization's sepsis revenue.
Whether you're coding for commercial insurance, Medicare Advantage, or state employee health programs, these changes affect your work immediately. Don't let your organization be caught off guard by the new reality of sepsis claim validation.
Join our Professional Reimbursement Network community for comprehensive insights that keep you ahead of industry changes. Subscribe now and share your sepsis coding strategies in the comments below!
Don't forget to LIKE, SUBSCRIBE, and hit that notification bell! Share this with your coding family—we all need to stay informed and stay strong.
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******REFERENCES******
https://www.horizonblue.com/providers...

https://www.cms.gov/files/document/fy...

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