R65
Symptoms and signs specifically associated with systemic inflammation and infection
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This code does not map to a risk-adjusting HCC in the loaded models.
Coding notes
Excludes 1 never coded together · Excludes 2 may co-exist
abnormal findings on antenatal screening of mother (O28.-) certain conditions originating in the perinatal period (P04-P96) signs and symptoms classified in the body system chapters signs and symptoms of breast (N63, N64.5)
This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded. Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification. The conditions and signs or symptoms included in categories R00-R94 consist of: (a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated; (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; (c) provisional diagnosis in a patient who failed to return for further investigation or care; (d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases in which a more precise diagnosis was not available for any other reason; (f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.
Official Guidelines for R65
FY 2026 ›Sections that reference R65
- I.C.1.d.6)Sepsis and severe sepsis associated with a noninfectious processChapter 1
… Only one code from category R65, Symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. …
- I.C.1.d.1)(a)SepsisChapter 1
… A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.
- I.C.1.d.1)(a)(i)Negative or inconclusive blood cultures and sepsisChapter 1
… the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis. …
- I.C.1.d.1)(b)Severe sepsisChapter 1
… sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. …
- I.C.1.d.2)Septic shockChapter 1
… For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Postprocedural septic shock. …
- I.C.1.d.3)Sequencing of severe sepsisChapter 1
… the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. …
Showing 6 of 15. Search the guidelines for R65. Sections whose FY 2026 text names R65, its R65 category, or a range containing it — the chapter guidance above is the authoritative source.