R65 Symptoms and signs specifically associated with systemic inflammation and infection

The ICD-10-CM code for Symptoms and signs specifically associated with systemic inflammation and infection is R65 (FY2026). It is a non-billable category code — select a more specific code below for claims.

Classification

Chapter

18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Section

R50-R69: General symptoms and signs (R50-R69)

Category R65

7 codes (4 billable)

FY2026 Status

Stable since FY2024

Official Coding Guidelines

Sepsis/severe sepsis associated with a noninfectious process

6) Sepsis and severe sepsis associated with a noninfectious process (condition) In some cases, a noninfectious process (condition) such as trauma, may lead to an infection which can result in sepsis or severe sepsis. If sepsis or severe sepsis is documented as associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced first, followed by the code for the resulting infection. If severe sepsis is present, a code from subcategory R65.2 should also be assigned with any associated organ dysfunction(s) codes. It is not necessary to assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of non-infectious origin, for these cases. If the infection meets the definition of principal diagnosis, it should be sequenced before the non-infectious condition. When both the associated non-infectious condition and the infection meet the definition of principal diagnosis, either may be assigned as principal diagnosis. Only one code from category R65, Symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. Therefore, when a non-infectious condition leads to an infection resulting in severe sepsis, assign the appropriate code from subcategory R65.2, Severe sepsis. Do not additionally assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of non- infectious origin. See Section I.C.18. SIRS due to non-infectious process

Repeated falls vs history of falling

d. Repeated falls Code R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated. Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls. When appropriate, both codes R29.6 and Z91.81 may be assigned together.

Source: CMS — ICD-10-CM Official Guidelines for Coding and Reporting, FY2026

References

• CMS — ICD-10-CM Official Code Set and Guidelines, FY2026
• CDC/NCHS — ICD-10-CM Files and Browser Tool