CommercialCoverageHigh impact
Acute Stroke and Sepsis Coding in Outpatient Setting
EmblemHealth·Emergency Medicine, Internal Medicine, Family Medicine +4 more·Coding
Effective date
Dec 6, 2024
We identified it
Jun 20, 2026
Summary
EmblemHealth and ConnectiCare will deny claims for acute stroke (I63.-) and sepsis (A41.-) diagnoses when billed in outpatient settings starting December 6, 2024. Claims will be denied with reason 'diagnosis/place of service mismatch' for specific outpatient POS codes including office visits, telehealth, and outpatient facilities.
Action Required
By December 6, 2024: Billing team must update claim review processes to flag and prevent submission of acute stroke (I63.-) or sepsis (A41.-) diagnoses with outpatient POS codes (11, 2, 10, 22, 31, 50, 19). Train staff to verify diagnosis appropriateness for place of service. Claims with these diagnosis/POS combinations will be automatically denied.