R65.2
Header — not billableSevere sepsis
The ICD-10 code for severe sepsis is R65.2.
R65.2 is a non-billable header code. It groups related conditions but cannot be used on its own for reimbursement — select one of the 2 more specific codes below.
Clinical notes
Code first
This code represents a manifestation of an underlying disease. Coding convention requires the underlying (etiology) code to be sequenced first, with this code listed second.
- underlying infection, such as:
- infection following a procedure (T81.4-)
- infections following infusion, transfusion and therapeutic injection (T80.2-)
- puerperal sepsis (O85)
- sepsis following complete or unspecified spontaneous abortion (O03.87)
- sepsis following ectopic and molar pregnancy (O08.82)
- sepsis following incomplete spontaneous abortion (O03.37)
- sepsis following (induced) termination of pregnancy (O04.87)
- sepsis NOS (A41.9)
Also known as
Alternate wording, synonyms, or specific conditions that fall under this code, listed to help confirm you've picked the right one.
- Infection with associated acute organ dysfunction
- Sepsis with acute organ dysfunction
- Sepsis with multiple organ dysfunction
- Systemic inflammatory response syndrome due to infectious process with acute organ dysfunction
Use additional code
This code represents an underlying condition. When a related manifestation is also present, coding convention calls for an additional code to be listed after this one.
- code to identify specific acute organ dysfunction, such as:
- acute kidney failure (N17.-)
- acute respiratory failure (J96.0-)
- critical illness myopathy (G72.81)
- critical illness polyneuropathy (G62.81)
- disseminated intravascular coagulopathy [DIC] (D65)
- encephalopathy (metabolic) (septic) (G93.41)
- hepatic failure (K72.0-)
Documentation support
General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.
- •This is a non-billable header code. Documentation must support a more specific child code before this diagnosis can be reported on a claim.
- •This code represents a manifestation. Documentation should identify the underlying condition, which must be coded first.
- •If the associated manifestation or related condition noted above is also documented, an additional code should be reported alongside this one.
- •As a general rule, code to the highest level of specificity supported by the documentation in the medical record.
Child codes under R65.2
Related codes in this category
- R65.1Systemic inflammatory response syndrome (SIRS) of non-infectious originnon-billable header
- R65.2Severe sepsisnon-billable header