R65.20

Billable

Severe sepsis without septic shock

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 serious infection that has triggered a severe inflammatory response throughout the body, but the patient has not yet gone into septic shock.

Coding Tips

•Always code the underlying infection site and organism when documented
•Severe sepsis requires evidence of organ dysfunction; document specific organ involvement

Clinical Significance

Severe sepsis without septic shock indicates serious systemic infection with organ dysfunction but maintained blood pressure, representing a critical condition requiring immediate intensive intervention. This diagnosis carries high mortality risk and resource utilization needs for organ support.

Documentation Requirements

✓Documented infection source or positive cultures
✓SIRS criteria met in response to infection
✓Evidence of acute organ dysfunction
✓Blood pressure maintained without vasopressor support
✓Laboratory markers of organ failure
✓ICU level care documentation
✓Antibiotic therapy administration
✓Source control measures when applicable

Commonly Confused Codes

R65.21 — Severe sepsis with septic shock (hypotension present)A41.9 — Sepsis, unspecified organism (without organ dysfunction)R65.11 — SIRS with organ dysfunction (non-infectious cause)R57.0 — Cardiogenic shock (heart failure cause)

Code Hierarchy

└R65Symptoms and signs specifically associated with systemic inflammation and infection └R65.2Severe sepsis └R65.20Severe sepsis without septic shock

└R65.20Severe sepsis without septic shock