According to the ICD-10-CM Official Guidelines for Coding and Reporting, when sepsis is documented with an associated acute organ dysfunction, it is classified as severe sepsis. The coding sequence requires the code for the underlying systemic infection (A41.9 for unspecified sepsis) to be listed first. This is followed by a code from subcategory R65.2 to identify severe sepsis. Since the scenario does not mention septic shock, the correct code is R65.20 (Severe sepsis without septic shock). Finally, the code for the specific acute organ dysfunction, J96.00 (Acute respiratory failure, unspecified), is reported to fully capture the patient's condition.

B: This option is incomplete. It fails to report the severe sepsis (R65.20) and the associated acute respiratory failure (J96.00), which are required by coding guidelines.

C: This option is incorrect because it reports R65.21 (Severe sepsis with septic shock). The clinical scenario does not provide documentation to support a diagnosis of septic shock.

D: This option is incomplete. The guidelines mandate assigning a code from subcategory R65.2 when sepsis is documented with an associated acute organ dysfunction.

1. Centers for Medicare & Medicaid Services (CMS). (2023). ICD-10-CM Official Guidelines for Coding and Reporting FY 2024.

Section I.C.1.d.1.a.i: "For a diagnosis of sepsis

assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified

assign code A41.9

Sepsis

unspecified organism." (Supports use of A41.9)

Section I.C.1.d.1.b.i: "For a diagnosis of severe sepsis

assign the appropriate code for the underlying systemic infection

followed by a code from subcategory R65.2

Severe sepsis... A code from subcategory R65.2 should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented." (Supports sequencing and use of R65.20)

Section I.C.1.d.1.b.i

Note: This section lists acute respiratory failure as an example of an associated acute organ dysfunction. (Supports coding J96.00)

2. American Academy of Professional Coders (AAPC). (2023). 2024 CPC® Study Guide. Chapter 11: ICD-10-CM Coding. The guide reiterates the official CMS guidelines for sepsis coding

emphasizing the requirement to code for the underlying infection

followed by the severe sepsis code (R65.2x)

and then the code(s) for the organ dysfunction(s). This confirms the structure A41.9

R65.20

J96.00.