Severe sepsis with septic shock R65. 21 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 R65. 21 became effective on October 1, 2021.
Septic shock – Code first the underlying systemic infection, such as 038.0 (Streptococcal septicemia), then code 995.92 for severe sepsis, then code 785.52 for septic shock and finally assign the code for the specific type of organ failure inherent to septic shock, such as 584.9 for acute renal failure.
If the patient has severe sepsis, a code from subcategory R65. 2 should also be assigned as a secondary diagnosis.
Any additional code(s) for other acute organ dysfunction should also be assigned. 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.
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. 12, Postprocedural septic shock. Additional codes are also required to report other acute organ dysfunctions.
(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.
If severe sepsis develops during the hospital stay, code the systemic infection code 995.92 and organ dysfunction should be sequenced as a secondary diagnosis. Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore represents a type of acute organ dysfunction.
According to the guidelines above, sepsis would be the appropriate principal diagnosis if it is the reason the patient is admitted, and meets the definition of principal diagnosis.
Coding tips: According to the guidelines, for all cases of documented septic shock, the code for the underlying systemic infection (i.e., sepsis) should be sequenced first, followed by code R65.
Similar to ICD-9-CM, an additional code may be assigned to identify the specific infection such as sepsis (A41. 9) in ICD-10-CM.
Per protocol, Code Sepsis is activated in patients who meet two or more systemic inflammatory response syndrome (SIRS) criteria due to a suspected infection to allow for early implementation of the sepsis bundle, which includes laboratory testing, fluid resuscitation, and antibiotic administration (Figure 1).