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Home/Diagnosis/ICD-10 Coding for Septic Shock

ICD-10 Coding for Septic Shock

R65.21

Complete ICD-10-CM coding and documentation guide for icd-10 coding for septic shock includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Severe Sepsis with Shock
Sepsis-induced Hypotension
severe sepsis with septic shock
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Key Information: ICD-10 Coding for Septic Shock

Essential facts and insights about ICD-10 Coding for Septic Shock

Use ICD-10 code R65.21 for severe sepsis with septic shock, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Severe sepsis with septic shock

Billable Code
R65.21
Billable

Diagnostic Criteria

clinical:
  • • Presence of hypotension unresponsive to fluids and need for vasopressors
documentation:
  • • Explicit documentation of 'septic shock' by the provider

Applicable To

  • • Septic shock

Important Notes

  • • R65.21 should never be the principal diagnosis; it must follow the code for the underlying infection.
Ancillary Codes

Additional codes that may be used with this diagnosis

A41.9

Sepsis, unspecified organism

Use to identify the underlying infection when the organism is unspecified.

N17.9

Acute kidney failure, unspecified

Use when acute kidney injury is documented as a complication of septic shock.

Frequently Asked Questions

What is the ICD-10 code for septic shock?

The ICD-10 code for septic shock is R65.21, which is used when severe sepsis is accompanied by shock.

How should septic shock be documented?

Septic shock should be documented with explicit mention of shock, hypotension unresponsive to fluids, lactate ≥4 mmol/L, and vasopressor use.

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