The coding of severe sepsis requires a minimum of two codes: first a code for the underlying systemic infection, followed by a code from subcategory R65. 2, Severe sepsis. If the causal organism is not documented, assign code A41. 9, Sepsis, unspecified organism, for the infection.
If septic shock is documented, A41. 9 and R65. 21 can be coded.
When sepsis is present on admission and due to a localized infection (not a device or post procedural), the sepsis code is sequenced first followed by the code for the localized infection.
Septicemia – There is NO code for septicemia in ICD-10. Instead, you're directed to a combination 'A' code for sepsis to indicate the underlying infection, such A41. 9 (Sepsis, unspecified organism) for septicemia with no further detail.
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.
21 Severe sepsis with septic shock.
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 .
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.
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.
New definitions: a) Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. b) Septic shock is a subset of sepsis in which profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.
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.
9: Fever, unspecified.
785.52 is a legacy non-billable code used to specify a medical diagnosis of septic shock. This code was replaced on September 30, 2015 by its ICD-10 equivalent.
The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-9 Code Edits are applicable to this code:
Sepsis is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This leads to blood clots and leaky blood vessels. They cause poor blood flow, which deprives your body's organs of nutrients and oxygen.
General Equivalence Map Definitions The ICD-9 and ICD-10 GEMs are used to facilitate linking between the diagnosis codes in ICD-9-CM and the new ICD-10-CM code set. The GEMs are the raw material from which providers, health information vendors and payers can derive specific applied mappings to meet their needs.