Severe sepsis with septic shock

This code signifies a life-threatening organ dysfunction caused by a dysregulated host response to infection, accompanied by persistent hypotension requiring vasopressors to maintain mean arterial pressure (MAP) ≥ 65 mmHg and a serum lactate level > 2 mmol/L despite adequate fluid resuscitation. It represents the most severe form of sepsis, indicating circulatory and cellular/metabolic abnormalities substantially increasing mortality.

Apply this code when documentation clearly indicates both severe sepsis (e.g., infection with acute organ dysfunction) and septic shock (e.g., vasopressor dependence for hypotension, elevated lactate). Supporting documentation includes physician notes detailing the criteria for septic shock, laboratory results (lactate, cultures), and evidence of organ dysfunction. This code is appropriate for patients presenting with or developing septic shock during their hospital stay.

• Always sequence the underlying infection code(s) first, followed by this code.
• Do not code this with T81.12- (postprocedural septic shock); these conditions are mutually exclusive.
• Ensure documentation explicitly states "septic shock" and provides evidence of organ dysfunction and vasopressor dependence.