R65.2

Severe sepsis

FY2027Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified/R50–R69 General symptoms and signs

Non-billable headerNot valid on its own. Use one of the more specific codes under it.

Code first
Use additional code
Excludes2

R65.2 is a non-billable ICD-10-CM code header for severe sepsis. Report a more specific code from it instead. It is part of the FY2027 code set, effective October 1, 2026. The more specific codes under it are R65.20 Severe sepsis without septic shock and R65.21 Severe sepsis with septic shock. Its coding notes include a Code first instruction, a Use additional code instruction and 4 Excludes2 entries.

Guidelines tips

From the FY2027 Official Guidelines. ICD10Ref adds no rules of its own.

Sepsis is coded to the underlying systemic infection, with A41.9 as the default. Urosepsis has no default code and the provider must be queried. R65.2 needs documented severe sepsis or associated organ dysfunction.

Guidelines I.C.1.d.1.aSepsis, severe sepsis and urosepsisRead the official text

Symptom and sign codes are acceptable when no definitive diagnosis has been established. They are not added for signs that are routinely associated with a diagnosis.

Guidelines I.C.18.a; I.C.18.bSymptom and sign codesRead the official text

Code first

If the underlying condition listed here is present and known, sequence it first.

This code

underlying infection, such as:
- infection following a procedure (T81.4-)
- infections following infusion, transfusion and therapeutic injection (T80.2-)
- puerperal sepsis (O85)
- sepsis following complete or unspecified spontaneous abortion (O03.87)
- sepsis following ectopic and molar pregnancy (O08.82)
- sepsis following incomplete spontaneous abortion (O03.37)
- sepsis following (induced) termination of pregnancy (O04.87)
- sepsis NOS (A41.9)

Use additional code

Add the listed code as a secondary code, if known.

This code

code to identify specific acute organ dysfunction, such as:
- acute kidney failure (N17.-)
- acute respiratory failure (J96.0-)
- critical illness myopathy (G72.81)
- critical illness polyneuropathy (G62.81)
- disseminated intravascular coagulopathy [DIC] (D65)
- encephalopathy (metabolic) (septic) (G93.41)
- hepatic failure (K72.0-)

Excludes2

Not included here. Both codes may be reported if the patient has both conditions.

Also from chapter/block level (4 notes)

Inherited from Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

abnormal findings on antenatal screening of mother (O28.-)
certain conditions originating in the perinatal period (P04-P96)
signs and symptoms classified in the body system chapters
signs and symptoms of breast (N63, N64.5)

Inclusion terms

Conditions classified to this code.

This code

Infection with associated acute organ dysfunction
Sepsis with acute organ dysfunction
Sepsis with multiple organ dysfunction
Systemic inflammatory response syndrome due to infectious process with acute organ dysfunction

Notes

Also from chapter/block level (9 notes)

Inherited from Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.
Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification.
The conditions and signs or symptoms included in categories R00-R94 consist of:
- (a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated;
- (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined;
- (c) provisional diagnosis in a patient who failed to return for further investigation or care;
- (d) cases referred elsewhere for investigation or treatment before the diagnosis was made;
- (e) cases in which a more precise diagnosis was not available for any other reason;
- (f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.

More specific codes under R65.2 2