Severe sepsis with septic shock
Billable / specificHCC V28 2
R65.21 is a billable, specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes in FY2027.
Inclusion terms
Includes (from R65)
- Note: This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.
- Note: Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification.
- Note: The conditions and signs or symptoms included in categories R00-R94 consist of:
- Note: (a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated;
- Note: (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined;
- Note: (c) provisional diagnosis in a patient who failed to return for further investigation or care;
- Note: (d) cases referred elsewhere for investigation or treatment before the diagnosis was made;
- Note: (e) cases in which a more precise diagnosis was not available for any other reason;
- Note: (f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.
Excludes1
Not coded here — never report together with this code.
- postprocedural septic shock (T81.12-)
Excludes2
Not included here — may be reported together when both conditions exist.
Code first
Sequence the underlying condition first.
- underlying infection, such as: (from R65.2)
- infection following a procedure (T81.4-) (from R65.2)
- infections following infusion, transfusion and therapeutic injection (T80.2-) (from R65.2)
- puerperal sepsis (O85) (from R65.2)
- sepsis following complete or unspecified spontaneous abortion (O03.87) (from R65.2)
- sepsis following ectopic and molar pregnancy (O08.82) (from R65.2)
- sepsis following incomplete spontaneous abortion (O03.37) (from R65.2)
- sepsis following (induced) termination of pregnancy (O04.87) (from R65.2)
- sepsis NOS (A41.9) (from R65.2)
Use additional code
Add a code to identify the following, if applicable.
- code to identify specific acute organ dysfunction, such as: (from R65.2)
- acute kidney failure (N17.-) (from R65.2)
- acute respiratory failure (J96.0-) (from R65.2)
- critical illness myopathy (G72.81) (from R65.2)
- critical illness polyneuropathy (G62.81) (from R65.2)
- disseminated intravascular coagulopathy [DIC] (D65) (from R65.2)
- encephalopathy (metabolic) (septic) (G93.41) (from R65.2)
- hepatic failure (K72.0-) (from R65.2)
Also known as
- Infection, infected, infective, with organ dysfunction, with septic shock
- Sepsis, with organ dysfunction, with septic shock
- Sepsis, severe, with septic shock
- Severe sepsis, with septic shock
- Shock, endotoxic
- Shock, gram-negative
- Shock, septic