ICD Code R65.2

ICD code R65.2 is severe sepsis.

1. Evidence of a systemic inflammatory response syndrome (SIRS) due to a confirmed or suspected infection

2. Presence of at least two of the following SIRS criteria:

a. Body temperature >38°C (100.4°F) or <36°C (96.8°F)

b. Heart rate >90 beats per minute

c. Respiratory rate >20 breaths per minute or arterial PaCO₂ <32 mm Hg

d. White blood cell count >12,000/mm³, <4,000/mm³, or >10% immature (band) forms

3. Clinical signs of organ dysfunction, hypoperfusion, or hypotension, such as:

a. Altered mental status

b. Systolic blood pressure <90 mm Hg or mean arterial pressure <70 mm Hg

c. Serum lactate above the upper limits of normal

d. Decreased urine output

e. Acute respiratory distress

f. Coagulation abnormalities

g. Elevated bilirubin or creatinine levels

Relevant CPT codes that may be used to treat ICD code R65.2 include:

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

- 99292 (Critical care, each additional 30 minutes)

- 31500 (Intubation, endotracheal, emergency procedure)

- 36620 (Arterial catheterization or cannulation for sampling, monitoring, or transfusion)

- 36415 (Collection of venous blood by venipuncture)

- 93010 (Electrocardiogram, interpretation and report)

- 71045 (Chest x-ray, single view)

- 94002-94004 (Ventilation management codes)

- 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour)

- 96372 (Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular)

CPT code selection should be based on the specific services rendered and clinical documentation.

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