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Home/Diagnosis/ICD-10 Coding for Severe Sepsis

ICD-10 Coding for Severe Sepsis

A41.9
R65.21

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

Also Known as:
Sepsis with Organ Dysfunction
Septic Shock
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Key Information: ICD-10 Coding for Severe Sepsis

Essential facts and insights about ICD-10 Coding for Severe Sepsis

Use ICD-10 code A41.9 for sepsis, unspecified organism, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Sepsis, unspecified organism

Billable Code
A41.9
Billable

Diagnostic Criteria

  • • Positive blood culture
  • • Clinical signs of systemic infection

Applicable To

  • • Sepsis NOS

Important Notes

  • • Ensure that the documentation explicitly links sepsis to organ dysfunction.

Severe sepsis with septic shock

Billable Code
R65.21
Billable

Diagnostic Criteria

  • • Lactate ≥2 mmol/L
  • • SBP <90 mmHg
  • • Vasopressor use

Applicable To

  • • Septic shock

Important Notes

  • • Ensure documentation supports the presence of shock.
Ancillary Codes

Additional codes that may be used with this diagnosis

J96.01

Acute respiratory failure with hypoxia

Used to specify respiratory failure as an organ dysfunction.

Frequently Asked Questions

What is the ICD-10 code for severe sepsis?

The ICD-10 code for severe sepsis is R65.20 for severe sepsis without septic shock and R65.21 for severe sepsis with septic shock.

How is severe sepsis documented?

Severe sepsis documentation requires explicit linkage between infection and organ dysfunction, using phrases like 'due to' or 'associated with'.

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