Severe sepsis without septic shock

This code signifies a life-threatening organ dysfunction caused by a dysregulated host response to infection, without the presence of persistent hypotension requiring vasopressors. It indicates a systemic inflammatory response to a suspected or confirmed infection, leading to acute organ damage.

Apply this code when documentation clearly states "severe sepsis" and specifies the presence of organ dysfunction (e.g., acute kidney injury, altered mental status, coagulopathy) but explicitly denies or does not mention septic shock. Supporting documentation should include evidence of infection and at least one new organ dysfunction attributable to the infection.

• Always code the underlying infection first, followed by this code.
• Do not use this code if the documentation indicates septic shock; instead, use the appropriate septic shock code.
• Ensure the medical record clearly identifies the specific organ dysfunction(s) present to support the "severe" designation.