Name: Severe sepsis
Creator: MedCoder.ai

Billing Status: NO. This is a non-billable ICD-10-CM code: report a more specific billable code beneath it.

Coding at a Glance

Official instructions: 4 inclusion terms · 8 use-additional instructions · 9 code-first instructions

What these terms mean →

Not billable · FY2027A non-billable heading in the tabular list: report a more specific code beneath it.

What you need to know

Source: CMS/NCHS Official ICD-10-CM tabular notes, quoted. From the CMS/NCHS tabular list for the release in force. A note the category or block publishes applies to this code too, and is marked with where it comes from.

Code firstSequence the underlying condition 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)
+5 more in Instructions
Use additional codeReport with this code when documented: 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)
+4 more in Instructions
IncludesWhat this code covers: 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

Where it sits Source: CMS/NCHS

Under:Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified R50-R69 General symptoms and signs R65 Symptoms and signs specifically associated with systemic inflammation and infection

Codes under R65.2 (2)

R65.20Severe sepsis without septic shockBillable
R65.21Severe sepsis with septic shockBillable

Most relevant related codes MedCoder-derived

Read off the official notes above and this code’s own position in the tabular list. Which to report is a documentation question; Compare shows the two side by side.

Compare Check Claim View Related Codes

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: FY2027Effective: October 1, 2026

Trace:FY2027 changes Change history Release, file and checksum

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 →

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. Where the codes beneath it include an unspecified code, that code applies when the record goes no further; otherwise query for the missing detail.
ReviewR65.20, R65.21
Is the underlying (etiologic) condition the Code First note names documented?
Yes → Sequence the underlying condition first, then the code beneath 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

Report the code beneath R65.2 that the documentation supports, not R65.2 itself. Then work the Use Additional Code note, and confirm that code is valid for the date of service on its own page.

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 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 the code beneath 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.

Coding context

Guidelines, coding notes, decision aids, relationships (with MS-DRG and CCSR classification), hierarchy, HCC, coverage and the context map: what a coder reaches for after the core. Each section names whether it is official source data, a MedCoder-derived relationship or MedCoder editorial.

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.