If severe sepsis is present, what additional code must be included when coding?

When severe sepsis is present, it is crucial to include a code for the organ dysfunction associated with it, as this accurately reflects the severity and complexity of the patient's condition. R65.2 is specifically used for severe sepsis and must be accompanied by the appropriate codes for the specific organ dysfunctions occurring, such as respiratory failure, acute kidney injury, or others.

This approach aligns with coding guidelines that aim to provide a complete clinical picture, indicating both the underlying severe sepsis and its effects on other organ systems. Just documenting severe sepsis without the associated organ dysfunction would not adequately convey the extent of the patient's condition and, thus, may lead to undercoding or misrepresentation of the patient's acuity.

Including additional codes, such as those for localized infections or noninfectious conditions, does not specifically address the need to capture organ dysfunction, which is a key element in managing and billing for cases of severe sepsis. The focus on documenting any organ dysfunction emphasizes the critical nature of severe sepsis and helps in maintaining clinical accuracy.