Sepsis Documentation Guide
Life-threatening organ dysfunction caused by a dysregulated host response to infection.
ICD-10 Codes: R65.20, R65.21, A41.01, A41.02, A41.1, A41.2, A41.50, A41.51, A41.52, A41.53, A41.59, A41.89, A41.9
Common Symptoms
- Fever or hypothermia
- Tachycardia
- Tachypnea
- Altered mental status
- Hypotension
Key Documentation Elements
- Sepsis criteria met (SIRS, qSOFA, SOFA score)
- Suspected or confirmed infection source
- Blood culture timing and results
- Antibiotic selection, timing, and de-escalation
- Organ dysfunction markers (lactate, creatinine, bilirubin)
Documentation Challenges
- Documenting sepsis criteria (qSOFA, SOFA) and onset time
- Capturing source of infection and organism identification
- Recording SEP-1 bundle compliance elements and timing
- Tracking organ dysfunction and severity progression
Billing Considerations
- Severe sepsis (R65.20) vs septic shock (R65.21) distinction
- Underlying organism coding (A41.x) required with R65.2x
- Critical care time documentation for billing
Frequently Asked Questions
What ICD-10 codes are used for sepsis?
Severe sepsis uses R65.20, septic shock uses R65.21, and underlying organism codes (A41.x) are required as additional codes. For example, MRSA sepsis uses A41.02 with R65.20. Scribeable captures organism and severity for dual coding.
How does Scribeable help with sepsis documentation?
Scribeable captures sepsis criteria, bundle element timing, organ dysfunction markers, antibiotic decisions, and culture results from your encounter, ensuring SEP-1 compliance documentation and accurate severity coding.