R65.2 — Severe sepsis
R65.2 is a non-billable header ICD-10-CM code for severe sepsis. It cannot be billed on its own: choose one of the more specific child codes below.
Code first
The underlying condition must be sequenced before this code.
- 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)
Use additional code
Add a secondary code to capture the detail described below.
- 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-)
Inclusion terms
Alternative wordings a physician may use in the chart for this same code.
- 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
Other codes that can never be billed with R65.2
These codes carry an Excludes1 note pointing at R65.2. The conflict binds both ways, but ICD-10-CM only writes it down on one side — so you would not find this by reading R65.2 alone.
Risk adjustment
R65.2 does not map to an HCC and does not risk-adjust under CMS-HCC V28. That is normal — most ICD-10 codes do not. It still needs to be coded correctly; it just will not move a RAF score.
Code to one of these instead R65.2
2 child codes. Green means billable.
Related codes at this level
Codes that share R65. If R65.2 is not quite right, the correct code is usually one of these.
Questions about R65.2
- Is R65.2 a billable ICD-10-CM code?
- No. R65.2 is a non-billable header code. Code to a higher level of specificity using one of its child codes.
- Where does R65.2 sit in the tabular list?
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99), in the block General symptoms and signs (R50-R69).