Severe sepsis without septic shock
ICD-10 R65.20 is a billable code used to indicate a diagnosis of severe sepsis without septic shock.
Severe sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. It is characterized by the presence of sepsis, which is defined as a systemic inflammatory response syndrome (SIRS) due to infection, along with evidence of organ dysfunction. Symptoms may include fever, chills, rapid heart rate, rapid breathing, confusion, and decreased urine output. Laboratory findings often reveal elevated white blood cell counts, abnormal liver function tests, and metabolic acidosis. Severe sepsis can progress to septic shock, but in this case, the patient does not exhibit the profound circulatory, cellular, and metabolic abnormalities associated with shock. Common causes include pneumonia, urinary tract infections, and abdominal infections. Early recognition and treatment are critical to improving outcomes.
Thorough documentation of vital signs, laboratory results, and clinical assessments is essential. Specific organ dysfunction must be noted.
Patients presenting with pneumonia or urinary tract infections leading to severe sepsis.
Internal medicine practitioners should ensure that all clinical findings are well-documented to support the diagnosis of severe sepsis.
Acute care documentation must include initial assessments, vital signs, and any interventions performed.
Patients arriving in the emergency department with fever, tachycardia, and altered mental status.
Emergency physicians should document the timeline of symptoms and interventions to support the diagnosis of severe sepsis.
Used for patients presenting with severe sepsis symptoms.
Document the severity of the condition and all relevant clinical findings.
Emergency medicine providers should ensure that the visit level reflects the complexity of the case.
Severe sepsis involves organ dysfunction due to infection without the profound hypotension seen in septic shock. Septic shock is characterized by persistent low blood pressure despite adequate fluid resuscitation.
