ICD Code R65.10

ICD code R65.10 is used to classify a condition known as Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction. This code is applied when a patient exhibits a systemic inflammatory response, such as fever, increased heart rate, or abnormal white blood cell count, that is not caused by an infection and does not result in immediate organ failure. It is important for healthcare providers to accurately document this condition to ensure proper treatment and billing processes.

1. Presence of Systemic Inflammatory Response Syndrome (SIRS): The patient must exhibit signs of SIRS, which is characterized by a systemic inflammatory response to a variety of severe clinical insults.

2. Non-Infectious Origin: The SIRS must be determined to be of non-infectious origin. This means that the inflammatory response is not due to an infection but rather other causes such as trauma, burns, pancreatitis, or other non-infectious conditions.

3. Absence of Acute Organ Dysfunction: The patient should not exhibit any signs of acute organ dysfunction. This includes the absence of acute failure or severe impairment of organs such as the heart, lungs, kidneys, liver, or brain.

4. Clinical Symptoms: The patient must present with at least two of the following clinical symptoms:

• Fever: A body temperature greater than 38°C (100.4°F) or hypothermia with a temperature less than 36°C (96.8°F).
• Tachycardia: A heart rate greater than 90 beats per minute.
• Tachypnea: A respiratory rate greater than 20 breaths per minute or an arterial carbon dioxide tension (PaCO2) less than 32 mm Hg.
• Leukocytosis or Leukopenia: A white blood cell count greater than 12,000/mm³, less than 4,000/mm³, or the presence of more than 10% immature (band) forms.

5. Exclusion of Infectious Causes: A thorough evaluation should be conducted to rule out infectious causes of the symptoms, ensuring that the SIRS is indeed of non-infectious origin.

6. Documentation: Proper documentation in the patient's medical record should reflect the presence of SIRS, its non-infectious origin, and the absence of acute organ dysfunction to support the use of this ICD code.

For the ICD code R65.10, which pertains to systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction, the relevant CPT codes that may be applicable include:

1. 99291 - Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

2. 99292 - Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).

3. 99468 - Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate or infant.

4. 99469 - Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate or infant.

5. 99471 - Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child.

6. 99472 - Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child.

7. 99475 - Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill child.

8. 99476 - Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill child.

These CPT codes are typically used in scenarios where critical care services are required, reflecting the intensive nature of managing a patient with systemic inflammatory response syndrome. It is important for healthcare providers to select the appropriate CPT code based on the specific services rendered and the patient's condition. Always ensure that documentation supports the level of care provided to justify the use of these codes.

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