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ICD-10 Coding for Septic Shock(R65.21)

Complete ICD-10-CM coding and documentation guide for Septic Shock. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Severe Sepsis with ShockSepsis-induced Hypotensionsevere sepsis with septic shocksepsis shock

Related ICD-10 Code Ranges

Complete code families applicable to Septic Shock

R65.2Primary Range

Severe sepsis

This range includes codes for severe sepsis, including septic shock, which is a critical condition requiring specific coding and documentation.

Bacterial sepsis

These codes are used to identify the underlying bacterial infection causing septic shock.

Key Information: ICD-10 code for septic shock

Essential facts and insights about Septic Shock

The ICD-10 code for septic shock is R65.21, used when severe sepsis is accompanied by shock.

Primary ICD-10-CM Code for septic shock

Severe sepsis with septic shock
Billable Code

Decision Criteria

clinical Criteria

  • Presence of hypotension unresponsive to fluids and need for vasopressors

documentation Criteria

  • Explicit documentation of 'septic shock' by the provider

Applicable To

  • Septic shock

Excludes

  • Sepsis without shock
  • Severe sepsis without shock

Clinical Validation Requirements

  • Documentation of septic shock
  • Refractory hypotension despite fluid resuscitation
  • Lactate level ≥4 mmol/L
  • Use of vasopressors

Code-Specific Risks

  • Incorrect sequencing if not following underlying infection code
  • Coding without sufficient clinical documentation

Coding Notes

  • R65.21 should never be the principal diagnosis; it must follow the code for the underlying infection.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Sepsis, unspecified organism

A41.9
Use to identify the underlying infection when the organism is unspecified.

Acute kidney failure, unspecified

N17.9
Use when acute kidney injury is documented as a complication of septic shock.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Severe sepsis without septic shock

R65.20
Use R65.20 when severe sepsis is present without the clinical criteria for shock.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Septic Shock to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R65.21.

Impact

Clinical: Misrepresentation of patient severity, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials

Mitigation Strategy

Regular training on documentation standards, Use of checklists for septic shock criteria

Impact

Reimbursement: Incorrect sequencing can lead to denied claims or reduced reimbursement., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data reporting.

Mitigation Strategy

Always sequence the underlying infection code first.

Impact

Inadequate documentation of clinical criteria for septic shock can lead to audit risks.

Mitigation Strategy

Ensure comprehensive documentation of all clinical indicators and treatments.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Septic Shock, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Septic Shock

Use these documentation templates to ensure complete and accurate documentation for Septic Shock. These templates include all required elements for proper coding and billing.

Septic shock in the emergency department

Specialty: Emergency Medicine

Required Elements

  • Documentation of hypotension unresponsive to fluids
  • Lactate levels
  • Vasopressor use
  • Underlying infection

Example Documentation

Patient presents with septic shock secondary to pneumonia. SBP 85/50 post 2L NS, lactate 5.2 mmol/L, started on norepinephrine.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient with hypotension and sepsis.
Good Documentation Example
Septic shock due to pneumonia with SBP 85/50 after fluids, lactate 5.2, on norepinephrine.
Explanation
The good example provides specific clinical indicators and treatment details, meeting coding criteria.

Need help with ICD-10 coding for Septic Shock? Ask your questions below.

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