R65.2 - Severe sepsis
|Short Description:||Severe sepsis|
|Long Description:||Severe sepsis|
|Status:||Not Valid for Submission|
R65.2 is a non-specific and non-billable ICD-10 code code, consider using a code with a higher level of specificity for a diagnosis of severe sepsis. The code is not specific and is NOT valid for the year 2023 for the submission of HIPAA-covered transactions. Category or Header define the heading of a category of codes that may be further subdivided by the use of 4th, 5th, 6th or 7th characters.
According to ICD-10-CM guidelines this code should not to be used as a principal diagnosis code when a related definitive diagnosis has been established.
Specific Coding for Severe sepsis
Non-specific codes like R65.2 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10 codes with a higher level of specificity when coding for severe sepsis:
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 coding notes and guidance for inclusions, exclusions, descriptions and more. The following references are applicable to this diagnosis code:
Inclusion TermsInclusion 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 FirstCode 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 CodeUse 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.
What is sepsis?
Sepsis is your body's overactive and extreme response to an infection. Sepsis is a life-threatening medical emergency. Without quick treatment, it can lead to tissue damage, organ failure, and even death.
What causes sepsis?
Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Bacterial infections are the most common cause, but other types of infections can also cause it.
The infections are often in the lungs, stomach, kidneys, or bladder. It's possible for sepsis to begin with a small cut that gets infected or with an infection that develops after surgery. Sometimes, sepsis can occur in people who didn't even know that they had an infection.
Who is at risk for sepsis?
Anyone with an infection could get sepsis. But certain people are at higher risk:
- Adults 65 or older
- People with chronic conditions, such as diabetes, lung disease, cancer, and kidney disease
- People with weakened immune systems
- Pregnant women
- Children younger than one
What are the symptoms of sepsis?
Sepsis can cause one or more of these symptoms:
- Rapid breathing and heart rate
- Shortness of breath
- Confusion or disorientation
- Extreme pain or discomfort
- Fever, shivering, or feeling very cold
- Clammy or sweaty skin
It's important to get medical care right away if you think you might have sepsis or if your infection is not getting better or is getting worse.
What other problems can sepsis cause?
Severe cases of sepsis can lead to septic shock, where your blood pressure drops to a dangerous level and multiple organs can fail.
How is sepsis diagnosed?
Your health care provider may use many tools to make a diagnosis:
- A medical history, which includes asking about your symptoms
- A physical exam, including checking vital signs (your temperature, blood pressure, heart rate, and breathing)
- Lab tests that check for signs of infection or organ damage
- Imaging tests such as an x-ray or a CT scan to find the location of the infection
Many of the signs and symptoms of sepsis can also be caused by other medical conditions. This may make sepsis hard to diagnose in its early stages.
What are the treatments for sepsis?
It is very important to get treatment right away. Treatment usually includes:
- Maintaining blood flow to organs. This may involve getting oxygen and intravenous (IV) fluids.
- Treating the source of the infection
- If needed, medicines to increase blood pressure
In serious cases, you might need kidney dialysis or a breathing tube. Some people need surgery to remove tissue damaged by the infection.
Can sepsis be prevented?
To prevent sepsis, you should try to prevent getting an infection:
- Take good care of any chronic health conditions that you have
- Get recommended vaccines
- Practice good hygiene, such as handwashing
- Keep cuts clean and covered until healed
NIH: National Institute of General Medical SciencesCenters for Disease Control and Prevention
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- FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
- FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
- FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
- FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
- FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
- FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
- FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
- FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016 (First year ICD-10-CM implemented into the HIPAA code set)