· 2022 ICD-10-CM Diagnosis Code R65.2 Severe sepsis 2016 2017 2018 2019 2020 2021 2022 Non-Billable/Non-Specific Code R65.2 should not be used for reimbursement purposes as there are multiple codes below it that contain a greater level of detail. The 2022 edition of ICD-10-CM R65.2 became effective on October 1, 2021.
· First, an appropriate code has to be selected for the underlying infection, such as, A41.51 (Sepsis due to Escherichia coli), and this should be followed by code R65.2, severe sepsis. If the causal organism is not documented, code A41.9, Sepsis, unspecified organism, should be assigned for the infection.
· But here, we will report a code R65.21(which indicates severe sepsis with septic shock) instead of R65.20(severe sepsis). For example: A patient is admitted with severe sepsis, septic shock with acute renal failure. ICD 10 code for severe sepsis, septic shock with acute renal failure is A41.9, R65.21, N17.9. Localized Infection:
· 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. One may also ask, how do you code 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.
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. 21 or T81.
ICD-10 | Severe sepsis with septic shock (R65. 21)
9: Sepsis, unspecified.
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.
If the patient is admitted with a localized infection, and develops Sepsis after admission, a code for the localized infection is assigned first, followed by a code for the Sepsis or Severe sepsis; If the organism causing the Sepsis is documented, use a code in subcategory A41 (e.g., A41. 51 Sepsis due to E. coli);
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.
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.
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.
ICD-10 code A41. 9 for Sepsis, unspecified organism is a medical classification as listed by WHO under the range - Certain infectious and parasitic diseases .
9: Fever, unspecified.
Overview. Sepsis is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues. When the infection-fighting processes turn on the body, they cause organs to function poorly and abnormally. Sepsis may progress to septic shock.
Sepsis associated with organ dysfunction distant from the site of infection.
Codes with this title are a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code. "In diseases classified elsewhere" codes are never permitted to be used as first listed or principle diagnosis codes.
R65.2 should not be used for reimbursement purposes as there are multiple codes below it that contain a greater level of detail.
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).
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.
Sepsis means potentially fatal condition caused when the body responses to the presence of infection or organisms in the blood.
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.
Severe sepsis is sepsis with acute organ dysfunction. Acute organ dysfunction can manifest in any organ, and frequently manifests clinically as shock, respiratory failure, acute kidney injury, hematologic or metabolic disturbances, or neurologic decline.
If the patient has severe sepsis, add R65.2- with the codes for specific organ dysfunctions.
For instance, if severe sepsis, pneumonia, and acute renal failure due to dehydration are documented, the code for severe sepsis may not be assigned because the acute renal failure is not stated as due to or associated with sepsis. If the documentation is unclear, query the physician.
Bacteremia . Bacteremia is a lab finding of infectious organisms in the blood. The patient has no clinical signs of sepsis or SIRS. Bacteremia may be transient, or may lead to sepsis. When a patient’s blood cultures are positive and not believed to be a contaminant, the patient is usually treated with antibiotics.
Documentation issues: Often, a patient with a localized infection may exhibit tachycardia, leukocytosis, tachypnea, and fever, but not truly have SIRS or sepsis. These are typical symptoms of any infection.
The discharge diagnoses were influenza with pneumonia bacterial superinfection, positive for pseudomonas, as well as acidosis, asthma exacerbation, hypoxemia, and chronic bronchitis. Sepsis and SIRS were not mentioned on the discharge summary, and are mentioned only sporadically throughout the progress notes.
You must query the physician when the term “sepsis syndrome” is documented as a final diagnosis. Know when to Query. Sepsis is a complicated condition to code, and it is often necessary to query the physician to code the case correctly.
Post-procedural Sepsis and Sepsis Due to a Device, Implant, or Graft. A systemic infection can occur as a complication of a procedure or due to a device, implant, or graft. This includes systemic infections due to wound infection, infusions, transfusions, therapeutic injections, implanted devices, and transplants.
Sepsis can be caused by fungi, candida, or viruses, as well. It is important to use the Alphabetic Index to select the appropriate code for the systemic infection. For example, if a patient is diagnosed with candidal sepsis due to a candida UTI, you would report B37.7 Candidal sepsis for the principal diagnosis and B37.49 Other urogenital candidiasis for the secondary diagnosis. Do not select a code from A40.- through A41.9.
Severe sepsis is sepsis with acute organ dysfunction. It occurs when one or more of the body’s organs is damaged from the inflammatory response. Any organ can be affected.
Documentation issues: A patient with a localized infection usually presents with tachycardia, leukocytosis, tachypnea, and/or fever. These are typical symptoms of any infection. It is up to the clinical judgment of the physician to decide whether the patient has sepsis.
Localized Infection. Almost any type of infection can lead to sepsis. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. When localized infections are contained, they tend to be self-limiting and resolve with antibiotics.
A 79-year-old patient presented to the emergency department (ED) with shortness of breath and was admitted with a diagnosis of community-acquired pneumonia. The vital signs and lab work done in the ED revealed that the patient had a fever, tachypnea, and leukocytosis, and the chest X-ray showed infiltrates. The sputum culture was positive for Pseudomonas aeruginosa. The patient had a six-day length of stay. The discharge diagnoses were Pseudomonas pneumonia, lactic acidosis, asthma exacerbation, hypoxemia, and chronic bronchitis. “Possible sepsis” was documented in the consulting physician’s note only.
A systemic infection can occur as a complication of a procedure or due to a device, implant, or graft. This includes systemic infections due to postoperative wound infections, infusions, transfusions, therapeutic injections, implanted devices, and transplants.
Septic shock refers to circulatory failure associated with severe sepsis. It is a life-threatening condition that happens when the exaggerated response to infection leads to dangerously low blood pressure (hypotension). Septic shock is a form of organ failure.
Amber, your documentation sample allows for coding of severe sepsis, because the physician has linked the organ failure to the sepsis. "ARF due to dehydration and sepsis"
If a patient has se psis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign ...
With the example given above, coders would capture sepsis and AKI. We would not query for severe sepsis because only one organ system is affected and per pediatric guidelines, unless the child has respiratory or cardiovascular failure, there must be 2 organ systems affected.
Per Guidelines, one may code Severe Sepsis IF: Septic Shock is documented. Sepsis is stated as causing an associated acute organ dysfunction. The term Severe Sepsis is documented; Best Practice would be to ask for the specific acute organ dysfunction.