R65.21 - Severe sepsis with septic shock

Version 2023
No Valid Principal Dx
ICD-10:R65.21
Short Description:Severe sepsis with septic shock
Long Description:Severe sepsis with septic shock
Status: Valid for Submission
Version:ICD-10-CM 2023
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)

R65.21 is a billable ICD-10 code used to specify a medical diagnosis of severe sepsis with septic shock. The code is valid during the fiscal year 2023 from October 01, 2022 through September 30, 2023 for the submission of HIPAA-covered transactions.

This code describes a circumstance which influences the patient's health status but not a current illness or injury. The code is unacceptable as a principal diagnosis.

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.

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

Clinical Information

Index to Diseases and Injuries References

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for this diagnosis code are found in the injuries and diseases index:

Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10 Code Edits are applicable to this code:

Convert to ICD-9 Code

Source ICD-10 CodeTarget ICD-9 Code
R65.21785.52 - Septic shock
Combination Flag - Multiple codes are needed to describe the source diagnosis code. Correct coding should be done based on contextual judgment.
R65.21995.92 - Severe sepsis
Combination Flag - Multiple codes are needed to describe the source diagnosis code. Correct coding should be done based on contextual judgment.

Patient Education


Sepsis

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:

What are the symptoms of sepsis?

Sepsis can cause one or more of these symptoms:

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:

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:

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:

NIH: National Institute of General Medical SciencesCenters for Disease Control and Prevention


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Shock

Shock happens when not enough blood and oxygen can get to your organs and tissues. It causes very low blood pressure and may be life-threatening. It often happens along with a serious injury.

There are several kinds of shock. Hypovolemic shock happens when you lose a lot of blood or fluids. Causes include internal or external bleeding, dehydration, burns, and severe vomiting and/or diarrhea. Septic shock is caused by infections in the bloodstream. A severe allergic reaction can cause anaphylactic shock. An insect bite or sting might cause it. Cardiogenic shock happens when the heart cannot pump blood effectively. This may happen after a heart attack. Neurogenic shock is caused by damage to the nervous system.

Symptoms of shock include:

Shock is a life-threatening medical emergency and it is important to get help right away. Treatment of shock depends on the cause.

NIH: National Heart, Lung, and Blood Institute


[Learn More in MedlinePlus]

Code History