ICD Code R65.20

ICD code R65.20 is used to identify severe sepsis without septic shock. This code is applied when a patient is diagnosed with a systemic inflammatory response syndrome (SIRS) due to an infection, which results in acute organ dysfunction but does not progress to septic shock, a more critical condition characterized by significant drops in blood pressure and potential organ failure. Proper documentation and coding of this condition are crucial for accurate billing and reimbursement in the healthcare revenue cycle.

1. Confirmed Infection: The patient must have a documented or clinically suspected infection. This can be identified through laboratory tests, imaging studies, or clinical evaluation that suggests the presence of an infectious process.

2. Systemic Inflammatory Response Syndrome (SIRS) Criteria: The patient should meet at least two of the following SIRS criteria:

• Body temperature higher than 38°C (100.4°F) or lower than 36°C (96.8°F).
• Heart rate exceeding 90 beats per minute.
• Respiratory rate greater than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) less than 32 mm Hg.
• White blood cell count greater than 12,000/mm³, less than 4,000/mm³, or more than 10% immature (band) forms.

3. Organ Dysfunction: Evidence of organ dysfunction must be present, which can include:

• Altered mental status or confusion.
• Hypoxemia, indicated by a low oxygen saturation level.
• Elevated serum lactate levels.
• Acute kidney injury, evidenced by increased creatinine levels or decreased urine output.
• Coagulation abnormalities, such as thrombocytopenia (low platelet count).
• Liver dysfunction, indicated by elevated bilirubin levels.

4. Absence of Septic Shock: The patient should not exhibit signs of septic shock, which is characterized by persistent hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate levels greater than 2 mmol/L despite adequate fluid resuscitation.

By ensuring these criteria are met, healthcare providers can accurately utilize the ICD code for severe sepsis without septic shock, facilitating appropriate documentation and treatment planning.

For the ICD code R65.20, which pertains to severe sepsis without septic shock, 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. 36415 - Collection of venous blood by venipuncture.

4. 87040 - Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates.

5. 87070 - Culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification of isolates.

6. 80053 - Comprehensive metabolic panel.

7. 80076 - Hepatic function panel.

8. 85025 - Complete blood count (CBC) with differential.

9. 85610 - Prothrombin time.

These CPT codes are commonly associated with the evaluation, management, and treatment procedures for patients diagnosed with severe sepsis without septic shock. It is important for healthcare providers to select the appropriate codes based on the specific services rendered and the clinical context.

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