ICD 10 code for severe sepsis, septic shock with acute renal failure is A41.9, R65.21, N17.9 If the patient admitted for sepsis or severe sepsis and localized infection (pneumonia or cellulitis), then we need to sequence the code in the following below order.
Severe sepsis with septic shock. The 2019 edition of ICD-10-CM R65.21 became effective on October 1, 2018. This is the American ICD-10-CM version of R65.21 - other international versions of ICD-10 R65.21 may differ.
Coding sepsis that is further specified as severe sepsis or sepsis with acute organ dysfunction requires the assignment of a minimum of two codes, a code for the underlying systemic infection and code from subcategory R65.2; Severe sepsis. Additional codes for any associated acute organ dysfunction should also be assigned.
N17.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM N17.9 became effective on October 1, 2021. This is the American ICD-10-CM version of N17.9 - other international versions of ICD-10 N17.9 may differ.
Severe sepsis – Code first the underlying systemic infection, such as 038.0 (Streptococcal septicemia), then code 995.92 for severe sepsis, and finally code the specific type of organ failure, such as 584.9 for acute renal failure.
R65. 21 Severe sepsis with septic shock - ICD-10-CM Diagnosis Codes.
If the patient has severe sepsis, a code from subcategory R65. 2 should also be assigned as a secondary diagnosis.
The code for septic shock cannot be assigned as a principal diagnosis. For septic shock, the code for the underlying infection should be sequenced first, followed by code R65. 21, Severe sepsis with septic shock or code T81.
ICD-10 code R65. 21 for Severe sepsis with septic shock is a medical classification as listed by WHO under the range - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified .
sepsis. Septic shock is a severe complication of sepsis that can include very low blood pressure, an altered mental state, and organ dysfunction. It has a hospital mortality rate of 30–50 percent , making it very dangerous if not treated quickly.
For cases of septic shock, a minimum of two codes is needed to report severe sepsis with septic shock. Chapter-specific guidelines state, “First code for the underlying systemic infection, followed by R65. 21, septic shock. If the causal organism is not documented, assign code A41.
As noted in the Tabular List, the code for septic shock cannot be assigned as the principal diagnosis. The Official Guidelines for Coding and Reporting Section I.C. 1.
(Septic shock cannot occur without sepsis and severe sepsis being present). You would need to add codes for the underlying condition (local infection) as well as codes for the organ dysfunction resulting from the sepsis that support the presence of severe sepsis.
Coding sepsis requires a minimum of two codes: a code for the systemic infection (e.g., 038. xx) and the code 995.91, SIRS due to infectious process without organ dysfunction. If no causal organism is documented within the medical record, query the physician or assign code 038.9, Unspecified septicemia.
According to AHA Coding Clinic® (Vol. 1, No. 3, p. 4), when a patient has SIRS and a localized infection, sepsis can no longer be coded and an ICD-10-CM code for sepsis cannot be assigned unless the physician specifically documents sepsis.
Sepsis as Principal Diagnosis Is sepsis always sequenced as the principal diagnosis when it is present on admission? Some may say yes, because after all, that's what is stated in the official coding guidelines. However, my answer to this question is no, not always.
Septic shock with acute organ dysfunction due to group a streptococcus. Septic shock with acute organ dysfunction due to group b streptococcus. Septic shock with acute organ dysfunction due to meningococcal septicemia.
Septic shock with acute organ dysfunction. Septic shock with acute organ dysfunction due to anaerobic septicemia. Septic shock with acute organ dysfunction due to chromobacterium. Septic shock with acute organ dysfunction due to coagulate-negative staphylococcu.
Severe sepsis with septic shock: Septic shock means severe sepsis associated with circulatory failure. Assign the code in the same above format (severe sepsis) as it represents the type of acute organ dysfunction. But here, we will report a code R65.21 (which indicates severe sepsis with septic shock) instead of R65.20 (severe sepsis).
Sepsis means potentially fatal condition caused when the body responses to the presence of infection or organisms in the blood. Choose the appropriate “A” code from the alphabetical index to indicate sepsis with type of infection or causal organism, if the doctor documents “Sepsis with type of infection or causal organism”.
If the doctor documents “Sepsis” but the type of infection or causal organism is not specified, then will assign the A41.9 code, which indicates Sepsis, unspecified organism.
Coding sepsis that is further specified as severe sepsis or sepsis with acute organ dysfunction requires the assignment of a minimum of two codes, a code for the underlying systemic infection and code from subcategory R65.2; Severe sepsis. Additional codes for any associated acute organ dysfunction should also be assigned.
Coding a diagnosis of sepsis can be a tricky proposition. There are several guidelines to consider and documentation must be reviewed carefully. Below is an overview of some of the guidelines with examples of guideline application.