What must be documented to assign a code from subcategory R65.2?

To assign a code from subcategory R65.2, it is necessary to document the presence of severe sepsis or acute organ dysfunction. This subcategory specifically pertains to conditions where there is a significant and serious response to infection, leading to systemic inflammation and the potential for multiple organ systems to be affected.

Severe sepsis refers to sepsis accompanied by acute organ dysfunction, indicating that the body is experiencing a severe response to infection, which is more critical than just the presence of infection alone. Documentation of these conditions is essential for accurate coding and for conveying the severity of the patient’s condition in the medical record. This information also affects treatment plans, resource allocation, and can impact outcomes data for healthcare facilities. Therefore, without documenting severe sepsis or acute organ dysfunction, coding from R65.2 would not be appropriate.