ICD-10 Guide

R65.2

Severe sepsis

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R65.2 is a billable code used to indicate a diagnosis of severe sepsis.

Key Diagnostic Point:

Severe sepsis is a life-threatening condition characterized by a systemic inflammatory response to infection, leading to organ dysfunction. It is defined by the presence of sepsis (infection with systemic inflammatory response syndrome) along with evidence of organ dysfunction, which may manifest as altered mental status, respiratory distress, renal impairment, or hypotension. Common symptoms include fever, chills, rapid heart rate, and confusion. Laboratory findings may reveal elevated white blood cell counts, increased lactate levels, and abnormal liver function tests. Severe sepsis can arise from various infections, including pneumonia, urinary tract infections, and abdominal infections. Early recognition and treatment are critical, as the condition can rapidly progress to septic shock, which is associated with higher morbidity and mortality rates.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

Differentiating between sepsis and severe sepsis
Identifying organ dysfunction criteria
Documenting the underlying infection source
Understanding the clinical presentation variability

Audit Risk Factors

Inadequate documentation of organ dysfunction
Failure to link the infection source to severe sepsis
Misclassification of sepsis severity
Lack of clear clinical indicators in the medical record

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed documentation of patient history, physical examination findings, and laboratory results indicating organ dysfunction.

Common Clinical Scenarios

Patients presenting with fever, tachycardia, and altered mental status due to pneumonia or urinary tract infections.

Billing Considerations

Ensure that all organ dysfunctions are clearly documented and linked to the underlying infection.

Emergency Medicine

Documentation Requirements

Acute care documentation must include vital signs, initial lab results, and any interventions performed.

Common Clinical Scenarios

Patients arriving with septic shock, requiring immediate resuscitation and intervention.

Billing Considerations

Rapid assessment and documentation of organ dysfunction are critical for accurate coding.

Coding Guidelines

Inclusion Criteria

Use R65.2 When

According to ICD
10 guidelines, severe sepsis must be coded with an underlying infection code and must demonstrate organ dysfunction
Documentation must clearly indicate the relationship between the infection and the organ dysfunction

Exclusion Criteria

Do NOT use R65.2 When

No specific exclusions found.

Related CPT Codes

99285CPT Code

Emergency department visit, high severity

Clinical Scenario

Used for patients presenting with severe sepsis in the emergency department.

Documentation Requirements

Must document the severity of the condition and the complexity of medical decision-making.

Specialty Considerations

Emergency physicians should ensure that all clinical findings are documented to support the level of service.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of severe sepsis, improving the ability to capture the complexity of the condition and its associated complications.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of severe sepsis, improving the ability to capture the complexity of the condition and its associated complications.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the difference between sepsis and severe sepsis?

Sepsis is defined as a systemic inflammatory response to infection, while severe sepsis includes sepsis with evidence of organ dysfunction. The distinction is crucial for accurate coding and treatment.

ICD-10 R65.2 is a billable code used to indicate a diagnosis of severe sepsis.