2025 ICD-10-CM code R65.21
Severe sepsis with septic shock.
Medical necessity for the diagnosis of severe sepsis with septic shock is established by the presence of clinical criteria indicating severe infection and organ dysfunction due to the infection.
Clinicians responsible for diagnosing and managing sepsis and septic shock include critical care specialists, infectious disease specialists, emergency medicine physicians, and hospitalists.
- Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R65.2 - Severe sepsis
In simple words: This code represents a serious infection that has spread throughout the body and caused dangerously low blood pressure.
Severe sepsis with septic shock is a life-threatening condition characterized by a whole-body inflammatory state (sepsis) and extremely low blood pressure (septic shock) caused by an infection.
Example 1: A patient admitted to the hospital with pneumonia develops fever, rapid heart rate, low blood pressure, and altered mental status, meeting the criteria for severe sepsis with septic shock., A patient with a urinary tract infection develops septic shock requiring vasopressors and intensive care management., A post-surgical patient develops an infection at the surgical site, which progresses to severe sepsis with septic shock.
Documentation should include evidence of infection, signs and symptoms of sepsis (e.g., fever, hypotension, tachycardia, tachypnea), and evidence of organ dysfunction (e.g., elevated creatinine, altered mental status).
- Specialties:Critical Care Medicine, Infectious Disease, Emergency Medicine, Internal Medicine, Hospital Medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital