ICD-10 Coding for Systemic Inflammatory Response Syndrome(R65.10, R65.11, R65.20, R65.21)
Complete ICD-10-CM coding and documentation guide for Systemic Inflammatory Response Syndrome. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Systemic Inflammatory Response Syndrome
R65.1-R65.2Primary Range
Systemic Inflammatory Response Syndrome (SIRS) and Severe Sepsis
This range includes codes for SIRS with and without organ dysfunction, and severe sepsis with and without shock.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R65.10 | Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction | Use when SIRS is diagnosed due to a non-infectious cause without organ dysfunction. |
|
| R65.11 | Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction | Use when SIRS is diagnosed due to a non-infectious cause with organ dysfunction. |
|
| R65.20 | Severe sepsis without septic shock | Use when severe sepsis is diagnosed without shock. |
|
| R65.21 | Severe sepsis with septic shock | Use when severe sepsis is diagnosed with shock. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for SIRS
Essential facts and insights about Systemic Inflammatory Response Syndrome
Primary ICD-10-CM Codes for sirs
Decision Criteria
clinical Criteria
- Presence of SIRS criteria without organ dysfunction
Applicable To
- SIRS due to non-infectious causes without organ failure
Excludes
- SIRS due to infectious causes (sepsis)
Clinical Validation Requirements
- Temperature >38°C or <36°C
- Heart rate >90 beats/min
- Respiratory rate >20 breaths/min or PaCO2 <32 mmHg
- White blood cell count >12,000/mm³ or <4,000/mm³ or >10% immature (band) forms
Code-Specific Risks
- Incorrectly coding as principal diagnosis when an underlying condition is present.
Coding Notes
- Ensure the underlying condition is documented and coded first.
R65.11 - Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction
Use when SIRS is diagnosed due to a non-infectious cause with organ dysfunction.
Applicable To
- SIRS due to non-infectious causes with organ failure
Excludes
- SIRS due to infectious causes (sepsis)
Clinical Validation Requirements
- SIRS criteria plus evidence of organ dysfunction such as acute renal failure, respiratory failure, etc.
Coding Notes
Ensure organ dysfunction is documented and coded.
R65.20 - Severe sepsis without septic shock
Use when severe sepsis is diagnosed without shock.
Applicable To
- Severe sepsis without shock
Excludes
- Septic shock (R65.21)
Clinical Validation Requirements
- Sepsis criteria plus evidence of organ dysfunction without shock.
Coding Notes
Ensure organ dysfunction is documented and coded.
R65.21 - Severe sepsis with septic shock
Use when severe sepsis is diagnosed with shock.
Applicable To
- Severe sepsis with shock
Clinical Validation Requirements
- Sepsis criteria plus evidence of organ dysfunction and shock.
Coding Notes
Ensure shock is documented and coded.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Systemic Inflammatory Response Syndrome to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R65.10.
Impact
Clinical: Inaccurate representation of patient severity., Regulatory: Non-compliance with coding guidelines., Financial: Potential loss of reimbursement.
Mitigation Strategy
Ensure thorough documentation of all clinical findings., Use templates to guide documentation.
Impact
Reimbursement: Incorrect sequencing can lead to denied claims., Compliance: Non-compliance with ICD-10-CM guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Always code the underlying condition first.
Impact
Reimbursement: Incorrect coding affects DRG assignment., Compliance: Potential audit issues., Data Quality: Misrepresentation of patient condition.
Mitigation Strategy
Ensure documentation specifies non-infectious vs. infectious causes.
Impact
Coding SIRS as principal diagnosis instead of underlying condition.
Mitigation Strategy
Educate coders on proper sequencing rules.
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 Systemic Inflammatory Response Syndrome, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Systemic Inflammatory Response Syndrome
Use these documentation templates to ensure complete and accurate documentation for Systemic Inflammatory Response Syndrome. These templates include all required elements for proper coding and billing.
Non-infectious SIRS due to pancreatitis
Specialty: GastroenterologyRequired Elements
- Underlying condition
- SIRS criteria
- Vital signs
- Lab results
- Organ dysfunction status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Systemic Inflammatory Response Syndrome? Ask your questions below.