R65.10

Billable

Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction

HCC Category Mapping

V28HCC 2 — Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

0.455

V24HCC 2 — Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

0.455

ESRDHCC 2 — Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

0.000

What This Code Means

A systemic inflammatory response in the body caused by non-infectious triggers (like trauma or burns) without organ failure.

Coding Tips

•This code requires documentation of SIRS criteria (fever/hypothermia, tachycardia, tachypnea, abnormal WBC)
•Distinguish from sepsis by confirming the inflammatory response is NOT due to infection

Clinical Significance

SIRS without organ dysfunction represents systemic inflammatory response to non-infectious triggers that requires careful monitoring to prevent progression to organ failure. Early recognition and treatment of underlying cause can prevent advancement to more severe systemic complications.

Documentation Requirements

✓Documentation of SIRS criteria met (temperature, heart rate, respiratory rate, WBC)
✓Non-infectious cause identified (trauma, burns, pancreatitis)
✓Absence of acute organ dysfunction
✓Laboratory values supporting inflammatory response
✓Underlying trigger documentation
✓Response to treatment measures
✓Monitoring for progression to organ dysfunction
✓ICU or step-down unit care if indicated

Commonly Confused Codes

R65.11 — SIRS with acute organ dysfunction (presence of organ failure)R65.20 — Severe sepsis without septic shock (infectious cause)A41.9 — Sepsis, unspecified organism (infectious etiology)R50.9 — Fever, unspecified (single symptom, not syndrome)

Code Hierarchy

└R65Symptoms and signs specifically associated with systemic inflammation and infection └R65.1Systemic inflammatory response syndrome (SIRS) of non-infectious origin └R65.10Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction

└R65.10Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction