Name: Severe sepsis
Creator: MedCoder.ai

Billing Status: NO. This is a clinician non-billable / parent hierarchy grouping in the ICD-10-CM system.

Coding at a Glance

Tabular directives: 4 inclusion terms · 8 use-additional codes · 9 code-first instructions

Coding instructions

Official Tabular Instructional Notes: the inclusion, exclusion and sequencing notes published for R65.2 in the official ICD-10-CM tabular list, quoted as published.

Source: CMS/CDC — ICD-10-CM Tabular ListRelease: FY2026Effective: October 1, 2025

Inclusion Terms

Alternative terms the tabular list files under 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

Code First

Underlying conditions that must be sequenced before 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

Supplementary codes the tabular list directs you to add.

Use additional 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
encephalopathy (metabolic) (septic) (G93.41)
hepatic failure (K72.0-)

Coder workflow for R65.2

MedCoder structured workflow — derived from this code’s own official record

Before you code R65.2

R65.2 is not reportable as written. Select the more specific code beneath it that the documentation supports. Codes are reported to the highest level of specificity the classification provides (Guidelines I.B.2).
ReviewR65.20, R65.21
See the relationships section · Guide: How to choose an ICD-10-CM code →
Check whether an established diagnosis that explains this sign or symptom is documented. If one is, review whether the documented diagnosis changes the coding pathway: a symptom that is integral to a confirmed diagnosis is not reported separately, while one not routinely associated with it may be. Signs and symptoms are reported when no definitive diagnosis is established (Guidelines I.B.4, I.B.5, I.B.6, I.C.18.b).
Guide: Symptom code vs confirmed diagnosis →

Choose the right path

Does the documentation support one of the more specific codes beneath R65.2?
Yes → Select that code and continue the checks below on its own page.
No → R65.2 cannot be reported as written; query for the specificity its subcategory needs.
ReviewR65.20, R65.21
Is an established diagnosis that explains this sign or symptom documented?
Yes → Review whether the documented diagnosis changes the coding pathway: a symptom integral to it is not reported separately.
No → Continue — the sign or symptom code stands when no definitive diagnosis is established.
Is the underlying (etiologic) condition the Code First note names documented?
Yes → Sequence the underlying condition first, then R65.2.
No → Continue; do not add an underlying condition the record does not document.
ReviewT81.4, T80.2, O85, O03.87, O08.82, O03.37

Consider R65.2. Then work the Use Additional Code note, and confirm the code is valid for the date of service in the Verify section.

Documentation check

The provider’s diagnostic statement: Codes are assigned from the provider’s documented diagnosis, not from clinical criteria, test values or a medication list (Guidelines I.A.19).
Severity: Mild, moderate or severe as the provider states it; severity is not inferred from the clinical picture.
The underlying (etiologic) condition: Named in the Code First note; sequenced before this code when documented (Guidelines I.A.13).
The conditions the Use Additional Code note names: Reported with this code when documented; a conditional instruction (“if applicable”, “if known”) applies only when the record supports it.

Official instructions as workflow

Code First — sequencing check(9 notes)
Coding workflow: Check whether the underlying or etiologic condition the note names is documented. When it is, sequence it before R65.2. Do not add an underlying condition the record does not document.
ReviewT81.4, T80.2, O85, O03.87, O08.82, O03.37
See the official tabular notes · Guidelines I.A.13
Use Additional Code — after identifying R65.2(8 notes)
Coding workflow: Check whether the documentation supports the additional code(s) the note names, and report them with R65.2 when it does. Where the instruction is conditional (“if applicable”, “if known”), it applies only when the record documents the condition.
ReviewN17, J96.0, G72.81, G62.81, G93.41, K72.0
See the official tabular notes · Guidelines I.A.13

Coding decision scenarios

Pattern scenarios for this code’s structure — decision rules, not clinical cases

Documentation: The sign or symptom is documented, and the same record establishes a diagnosis that routinely includes it.

Coding question: Is R65.2 reported in addition to the diagnosis?

Path: Review the documented diagnosis and whether the classification treats this finding as integral to it.

Reason: Signs and symptoms integral to a confirmed diagnosis are not coded separately; those not routinely associated with it may be reported when present (Guidelines I.B.5, I.B.6, I.C.18.b).

Documentation: The underlying condition the Code First note names is documented alongside this condition.

Coding question: How are the two sequenced?

Path: Review the Code First note.

Reason: The underlying condition is sequenced first and the manifestation follows (Guidelines I.A.13).

ReviewT81.4, T80.2, O85, O03.87, O08.82, O03.37

Documentation: A condition the Use Additional Code note names is documented.

Coding question: Is a second code reported with R65.2?

Path: Review the Use Additional Code note and the code it names.

Reason: The additional code is reported when the record documents the condition; a conditional instruction applies only when its condition is met (Guidelines I.A.13).

ReviewN17, J96.0, G72.81, G62.81, G93.41, K72.0

Every row is derived from this code’s own record — its title, tabular notes, 7th-character family and same-category siblings — with fixed MedCoder wording; nothing is inferred about a patient. The official notes and guideline text are in the sections each row links to, and they control.

Code Overview

Severe sepsis is a non-billable ICD-10-CM category code (R65.2). A more specific billable subcode must be selected for claims submission.

MedCoder summary Summary composed by MedCoder from this code's official ICD-10-CM record. The tabular instructional notes themselves appear verbatim below.

Official Coding Guidelines

Official source data — quoted verbatim from the CMS/NCHS Official Guidelines

Verbatim excerpts from the ICD-10-CM Official Guidelines for Coding and Reporting (CMS/NCHS) that govern this code.