2025 ICD-10-CM code R65.2
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings - General symptoms and signs Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Severe sepsis; infection with associated acute organ dysfunction.
Modifiers may be applicable depending on the circumstances of the service, such as the place of service and the provider's role.
Medical necessity for the diagnosis of severe sepsis is established by the presence of documented infection and evidence of acute organ dysfunction.The severity of the sepsis and the need for intensive care justify the diagnosis.
Diagnosis and management of severe sepsis, including identification of the underlying infection, assessment of organ dysfunction, initiation of appropriate treatment (antibiotics, supportive care), and monitoring of the patient's response to therapy.Collaboration with specialists (e.g., nephrologist, pulmonologist, intensivist) may be necessary depending on the severity and organ involvement.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R65 - Symptoms and signs specifically associated with systemic inflammation and infection
In simple words: Severe sepsis is a serious illness where an infection causes the body's response to become overwhelming and damage organs.It needs a confirmed infection and evidence of organ damage like kidney or lung problems.Doctors use additional codes to describe the specific organ problems and type of infection.
Severe sepsis is defined as sepsis with associated acute organ dysfunction.This indicates a life-threatening organ dysfunction caused by a dysregulated host response to infection.The code requires documentation of an underlying infection and at least one specific acute organ dysfunction. Additional codes should be used to identify the specific organ dysfunction and the underlying infection. Examples of organ dysfunction include acute kidney failure, acute respiratory failure, critical illness myopathy, critical illness polyneuropathy, disseminated intravascular coagulopathy (DIC), encephalopathy, and hepatic failure.Examples of underlying infections include those following a procedure, those following infusions or transfusions, puerperal sepsis, sepsis following abortion (spontaneous or induced), and sepsis of unspecified origin.
Example 1: A 70-year-old male patient presents to the emergency department with fever, hypotension, tachycardia, and altered mental status. Blood cultures reveal gram-negative bacteremia.He is diagnosed with severe sepsis secondary to pneumonia, with associated acute respiratory distress syndrome (ARDS).Additional codes would reflect the pneumonia (e.g., J18.9 Pneumonia, unspecified organism), and the ARDS (J96.9 Acute respiratory failure, unspecified)., A 35-year-old female patient is admitted post-cesarean section with fever, chills, and hypotension.She is found to have a uterine infection and is diagnosed with severe sepsis, with associated acute kidney injury (AKI). Additional codes would identify the puerperal sepsis (O85), and the AKI (N17.-)., A 25-year-old male patient is admitted following a motor vehicle accident with multiple injuries and develops fever, tachycardia, and hypotension. He is diagnosed with severe sepsis secondary to a post-surgical infection with associated disseminated intravascular coagulation (DIC). Additional codes would reflect the underlying injuries, the surgical site infection, and the DIC (D65).
* Detailed history and physical examination, including vital signs and assessment of organ function.* Laboratory data: Complete blood count (CBC), blood cultures, electrolytes, creatinine, coagulation studies, lactate levels.* Imaging studies as indicated (e.g., chest X-ray, CT scan).* Documentation of the underlying infection (source, type of organism).* Specific documentation of at least one acute organ dysfunction.* Documentation of the severity of the sepsis and the patient's response to treatment.
** This code is complex and requires careful documentation to ensure accurate coding.Consult the official ICD-10-CM guidelines and coding resources for additional clarification.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Infectious Disease, Critical Care, Emergency Medicine, Surgery
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Intensive Care Unit, Outpatient Hospital