2024 ICD-10-CM Diagnosis Code R65.21

Severe sepsis with septic shock

ICD-10-CM Code:
R65.21
ICD-10 Code for:
Severe sepsis with septic shock
Is Billable?
Yes - Valid for Submission
Chronic Condition Indicator: [1]
Not chronic
Code Navigator:

Code Classification

  • Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
    (R00–R99)
    • General symptoms and signs
      (R50-R69)
      • Symptoms and signs specifically associated with systemic inflammation and infection
        (R65)

R65.21 is a billable diagnosis code used to specify a medical diagnosis of severe sepsis with septic shock. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024.

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:

  • Endotoxemia
  • Endotoxemia
  • Endotoxic shock
  • Endotoxicosis
  • Endotoxicosis
  • Failed attempted termination of pregnancy complicated by shock
  • Failed attempted termination of pregnancy with septic shock
  • Hyperdynamic septic shock
  • Hypodynamic septic shock
  • Induced termination of pregnancy complicated by infectious disease
  • Induced termination of pregnancy complicated by postoperative shock
  • Induced termination of pregnancy complicated by septic shock
  • Induced termination of pregnancy complicated by shock
  • Miscarriage complicated by shock
  • Miscarriage with septic shock
  • Postprocedural septic shock
  • Pyrogenic shock
  • Sepsis caused by Chromobacterium
  • Septic shock
  • Septic shock co-occurrent with acute organ dysfunction caused by anaerobic bacteria
  • Septic shock co-occurrent with acute organ dysfunction caused by Haemophilus influenzae
  • Septic shock co-occurrent with acute organ dysfunction caused by Meningococcus
  • Septic shock co-occurrent with acute organ dysfunction caused by methicillin resistant Staphylococcus aureus
  • Septic shock co-occurrent with acute organ dysfunction caused by methicillin susceptible Staphylococcus aureus
  • Septic shock co-occurrent with acute organ dysfunction caused by methicillin susceptible Staphylococcus aureus
  • Septic shock co-occurrent with acute organ dysfunction caused by Pneumococcus
  • Septic shock co-occurrent with acute organ dysfunction caused by Pseudomonas
  • Septic shock co-occurrent with acute organ dysfunction caused by Serratia
  • Septic shock co-occurrent with acute organ dysfunction caused by Streptococcus
  • Septic shock co-occurrent with acute organ dysfunction caused by Streptococcus
  • Septic shock co-occurrent with acute organ dysfunction caused by Streptococcus
  • Septic shock co-occurrent with acute organ dysfunction caused by Streptococcus
  • Septic shock co-occurrent with acute organ dysfunction due to Chromobacterium
  • Septic shock co-occurrent with acute organ dysfunction due to coagulase-negative Staphylococcus
  • Septic shock co-occurrent with acute organ dysfunction due to Enterococcus
  • Septic shock co-occurrent with acute organ dysfunction due to Gonococcus
  • Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
  • Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
  • Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
  • Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
  • Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
  • Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
  • Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
  • Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
  • Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
  • Septic shock co-occurrent with acute organ dysfunction due to Group A streptococcus
  • Septic shock co-occurrent with acute organ dysfunction due to Group B streptococcus
  • Septic shock co-occurrent with acute organ dysfunction due to Staphylococcus
  • Septic shock co-occurrent with acute organ dysfunction due to Staphylococcus
  • Septic shock co-occurrent with acute organ dysfunction due to Staphylococcus
  • Septic shock co-occurrent with acute organ dysfunction due to Staphylococcus
  • Septic shock due to transfusion
  • Septic shock following ectopic pregnancy
  • Septic shock following molar pregnancy
  • Shock due to ectopic pregnancy
  • Shock following molar pregnancy

Clinical Classification

Clinical CategoryCCSR Category CodeInpatient Default CCSROutpatient Default CCSR
SepticemiaINF002X - Not applicable.Y - Yes, default outpatient assignment for principal diagnosis or first-listed diagnosis.
ShockSYM003X - Not applicable.N - Not default outpatient assignment for principal diagnosis or first-listed diagnosis.

Clinical Information

  • Endotoxemia

    a condition characterized by the presence of endotoxins in the blood. on lysis, the outer cell wall of gram-negative bacteria enters the systemic circulation and initiates a pathophysiologic cascade of pro-inflammatory mediators.
  • Endotoxins

    toxins closely associated with the living cytoplasm or cell wall of certain microorganisms, which do not readily diffuse into the culture medium, but are released upon lysis of the cells.

Index to Diseases and Injuries References

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

Code Edits

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

  • Unacceptable principal diagnosis - There are selected codes that describe a circumstance which influences an individual's health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis.

Convert R65.21 to ICD-9-CM

  • ICD-9-CM Code: 785.52 - Septic shock
    Combination Flag - Multiple codes are needed to describe the source diagnosis code. Correct coding should be done based on contextual judgment.
  • ICD-9-CM Code: 995.92 - 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:

  • 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:

  • Antibiotics
  • 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


[Learn More in MedlinePlus]

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:

  • Confusion or lack of alertness
  • Loss of consciousness
  • Sudden and ongoing rapid heartbeat
  • Sweating
  • Pale skin
  • A weak pulse
  • Rapid breathing
  • Decreased or no urine output
  • Cool hands and feet

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

  • FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
  • 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. This was the first year ICD-10-CM was implemented into the HIPAA code set.

Footnotes

[1] Not chronic - A diagnosis code that does not fit the criteria for chronic condition (duration, ongoing medical treatment, and limitations) is considered not chronic. Some codes designated as not chronic are acute conditions. Other diagnosis codes that indicate a possible chronic condition, but for which the duration of the illness is not specified in the code description (i.e., we do not know the condition has lasted 12 months or longer) also are considered not chronic.