ICD Code R65.21

ICD code R65.21 is used to classify a diagnosis of severe sepsis accompanied by septic shock. This code indicates a critical condition where the body's response to infection leads to dangerously low blood pressure and abnormalities in cellular metabolism, requiring immediate medical intervention.

1. Confirmed Diagnosis of Sepsis: The patient must have a confirmed diagnosis of sepsis, which is a life-threatening organ dysfunction caused by a dysregulated host response to infection.

2. Evidence of Organ Dysfunction: There should be clinical evidence of organ dysfunction, which may include acute kidney injury, liver dysfunction, altered mental status, or respiratory failure, among others.

3. Presence of Septic Shock: The patient must exhibit signs of septic shock, characterized by persistent hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mm Hg or greater, and having a serum lactate level greater than 2 mmol/L despite adequate volume resuscitation.

4. Infection Source Identification: There should be identification or strong suspicion of an infection source, such as pneumonia, urinary tract infection, or abdominal infection, which is contributing to the sepsis.

5. Clinical Symptoms of Severe Sepsis: The patient should present with symptoms indicative of severe sepsis, such as fever, tachycardia, tachypnea, and signs of systemic inflammation.

6. Laboratory Findings: Supporting laboratory findings may include elevated white blood cell count, elevated procalcitonin levels, or positive blood cultures indicating the presence of a pathogen.

7. Exclusion of Other Causes: Other potential causes of the patient's symptoms and organ dysfunction should be ruled out to confirm the diagnosis of severe sepsis with septic shock.

8. Documentation in Medical Records: The diagnosis and criteria for severe sepsis with septic shock should be clearly documented in the patient's medical records by the healthcare provider.

For the ICD code R65.21, which pertains to severe sepsis with 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. 80053 - Comprehensive metabolic panel.

5. 80076 - Hepatic function panel.

6. 87040 - Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates.

7. 87186 - Susceptibility studies, antimicrobial agent; microdilution or agar dilution method, each multi-antimicrobial agent panel.

8. 93010 - Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

9. 94660 - Continuous positive airway pressure ventilation (CPAP), initiation and management.

10. 94664 - Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device.

These CPT codes are commonly associated with the management and treatment of conditions related to severe sepsis with septic shock, as indicated by ICD code R65.21. It is important for healthcare providers to ensure accurate coding to facilitate proper billing and reimbursement processes.

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