ICD-10-CM Code R65.2

Severe sepsis

Version 2020 Non-Billable Code No Valid Principal Dx

Not Valid for Submission

R65.2 is a "header" nonspecific and non-billable code code, consider using a code with a higher level of specificity for a diagnosis of severe sepsis. The code is NOT valid for the year 2020 for the submission of HIPAA-covered transactions.

ICD-10:R65.2
Short Description:Severe sepsis
Long Description:Severe sepsis

Consider the following ICD-10 codes with a higher level of specificity:

  • R65.20 - Severe sepsis without septic shock
  • R65.21 - Severe sepsis with septic shock

Tabular List of Diseases and Injuries

The Tabular List of Diseases and Injuries is a list of ICD-10 codes, organized "head to toe" into chapters and sections with guidance for inclusions, exclusions, descriptions and more. The following references are applicable to the code R65.2:

Inclusion Terms

Inclusion Terms
These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
  • Infection with associated acute organ dysfunction
  • Sepsis with acute organ dysfunction
  • Sepsis with multiple organ dysfunction
  • Systemic inflammatory response syndrome due to infectious process with acute organ dysfunction

Code First

Code First
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
  • underlying infection, such as:
  • infection following a procedure T81.4
  • infections following infusion, transfusion and therapeutic injection T80.2
  • puerperal sepsis O85
  • sepsis following complete or unspecified spontaneous abortion O03.87
  • sepsis following ectopic and molar pregnancy O08.82
  • sepsis following incomplete spontaneous abortion O03.37
  • sepsis following induced termination of pregnancy O04.87
  • sepsis NOS A41.9

Use Additional Code

Use Additional Code
The “use additional code” indicates that a secondary code could be used to further specify the patient’s condition. This note is not mandatory and is only used if enough information is available to assign an additional code.
  • code to identify specific acute organ dysfunction, such as:
  • acute kidney failure N17
  • acute respiratory failure J96.0
  • critical illness myopathy G72.81
  • critical illness polyneuropathy G62.81
  • disseminated intravascular coagulopathy DIC D65
  • encephalopathy metabolic septic G93.41
  • hepatic failure K72.0

Clinical Information

  • SEPSIS-. systemic inflammatory response syndrome with a proven or suspected infectious etiology. when sepsis is associated with organ dysfunction distant from the site of infection it is called severe sepsis. when sepsis is accompanied by hypotension despite adequate fluid infusion it is called septic shock.

Code Classification

  • Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00–R99)
    • General symptoms and signs (R50-R69)
      • Symp and signs specifically assoc w sys inflam and infct (R65)

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (First year ICD-10-CM implemented into the HIPAA code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020

Information for Patients


Sepsis

Sepsis is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This leads to blood clots and leaky blood vessels. They cause poor blood flow, which deprives your body's organs of nutrients and oxygen. In severe cases, one or more organs fail. In the worst cases, blood pressure drops and the heart weakens, leading to septic shock.

Anyone can get sepsis, but the risk is higher in

  • People with weakened immune systems
  • Infants and children
  • Adults 65 and older
  • People with chronic illnesses, such as diabetes, AIDS, cancer, and kidney or liver disease
  • People suffering from a severe burn or physical trauma

Common symptoms of sepsis are fever, chills, rapid breathing and heart rate, rash, confusion, and disorientation. Doctors diagnose sepsis using a blood test to see if the number of white blood cells is abnormal. They also do lab tests that check for signs of infection.

People with sepsis are usually treated in hospital intensive care units. Doctors try to treat the infection, sustain the vital organs, and prevent a drop in blood pressure. Many patients receive oxygen and intravenous (IV) fluids. Other types of treatment, such as respirators or kidney dialysis, may be necessary. Sometimes, surgery is needed to clear up an infection.

NIH: National Institute of General Medical Sciences


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