Sepsis Coding in ICD-10-CM: Sepsis, Severe Sepsis, and Shock

Code sets: FY 2027 ICD-10-CM.

Sepsis

Assign the code for the underlying systemic infection. If the organism is not specified, use A41.9 Sepsis, unspecified organism. Do not add R65.2- (severe sepsis) unless severe sepsis or an associated acute organ dysfunction is documented (FY 2027 ICD-10-CM Guidelines, Section I.C.1.d).

There is no code for “septicemia” in ICD-10-CM; it is coded as sepsis. Bacteremia (R78.81) is a different condition: bacteria in the blood without the systemic response of sepsis.

Terms that trip coders up

• Urosepsis is not sepsis and has no default code. Query the provider. If the provider means a urinary tract infection, that is N39.0; if the provider means sepsis due to a UTI, both conditions are coded.
• Negative or inconclusive blood cultures do not rule out sepsis when the provider documents it, but the provider should be queried.
• Organ dysfunction not linked to sepsis: if the record says an acute organ dysfunction is due to another condition, do not assign R65.2-. If the link is unclear, query.

Severe sepsis and septic shock

• Severe sepsis needs at least two codes: the underlying systemic infection first, then R65.20 Severe sepsis without septic shock, plus codes for each acute organ dysfunction.
• Septic shock is a form of acute organ dysfunction: the infection first, then R65.21 Severe sepsis with septic shock (or T81.12- for postprocedural septic shock), plus the organ dysfunction codes.
• R65.2- codes can never be the principal diagnosis.

Sequencing with a localized infection

If the patient is admitted with sepsis and a localized infection such as pneumonia, the systemic infection code goes first and the pneumonia second. If the patient is admitted for pneumonia and sepsis develops later, the pneumonia goes first.

Postprocedural sepsis

Sequence the surgical site infection code first (T81.41-T81.43 or T81.49), then T81.44 Sepsis following a procedure, plus the organism. Code assignment depends on the provider documenting the link to the procedure.

In outpatient and risk adjustment work

Sepsis is usually an inpatient diagnosis. Be careful coding active sepsis from an office note weeks after discharge; that is usually a history or follow-up situation, not current sepsis.

Refreshed from the CCO Community archive, November 2026.