R65.21

HCC Category Mapping

What This Code Means

A life-threatening condition where a serious infection has caused severe inflammation and the patient's blood pressure has dropped dangerously low despite treatment.

Coding Tips

• •This is a medical emergency; code the specific infection source and causative organism
• •Document vasopressor use and organ dysfunction to support the septic shock diagnosis

Clinical Significance

Severe sepsis with septic shock represents the most critical form of sepsis where systemic infection has progressed to multi-organ dysfunction with cardiovascular collapse despite adequate fluid resuscitation. This diagnosis carries extremely high mortality rates and requires immediate intensive care management with vasopressors, broad-spectrum antibiotics, and aggressive supportive care.

Documentation Requirements

• ✓Documentation of sepsis or severe sepsis as the underlying condition
• ✓Evidence of shock (hypotension, need for vasopressors, or organ hypoperfusion)
• ✓Documentation that shock persists despite adequate fluid resuscitation
• ✓Identification of infectious source or suspected infection
• ✓Laboratory evidence supporting sepsis (elevated lactate, procalcitonin, or other biomarkers)
• ✓Evidence of organ dysfunction (acute kidney injury, respiratory failure, altered mental status)
• ✓Documentation of systemic inflammatory response syndrome (SIRS) criteria
• ✓Treatment with vasopressors or inotropic agents

Commonly Confused Codes