2025 ICD-10-CM code A41.2

Sepsis due to an unspecified strain of Staphylococcus.

Code A41.2 is used when the documentation clearly indicates sepsis due to Staphylococcus but does not specify the strain. Do not code sepsis and bacteremia separately when the bacteremia is causing the sepsis.

Sepsis is a life-threatening condition requiring urgent medical attention.Medical necessity for treatment is typically established by the presence of clinical indicators of sepsis and confirmed or suspected infection.

Clinicians should document the signs and symptoms of sepsis (e.g., fever, hypotension, tachycardia, altered mental status) and the evidence of Staphylococcus infection (e.g., positive blood cultures). It is crucial to initiate prompt treatment, which typically includes antibiotics and supportive care.

IMPORTANT If the specific strain of Staphylococcus is known (e.g., Methicillin-resistant Staphylococcus aureus (MRSA)), use codes A41.01 or A41.02. For Staphylococcal bacteremia without sepsis, use code R78.81.

In simple words: This code indicates a serious infection throughout the body caused by Staphylococcus bacteria, where the exact type of Staph isn't identified.Sepsis is a life-threatening condition.

A systemic inflammatory response syndrome (SIRS) resulting from a documented infection with Staphylococcus bacteria.The specific strain of Staphylococcus is not specified in the diagnostic documentation.

Example 1: A patient presents to the emergency room with fever, chills, and rapid breathing. Blood cultures reveal the presence of Staphylococcus, but the specific strain is not yet identified. The patient is diagnosed with sepsis due to unspecified Staphylococcus (A41.2)., A postoperative patient develops a wound infection confirmed to be caused by Staphylococcus. The infection spreads systemically, leading to sepsis.Initial cultures do not identify the Staph strain, therefore A41.2 is used., A patient with a central venous catheter develops fever and hypotension. Blood cultures grow Staphylococcus, but further testing to determine the specific type is pending. The physician documents sepsis due to unspecified Staphylococcus (A41.2).

Documentation should include signs and symptoms of sepsis, evidence of infection (e.g., positive cultures, imaging findings), and any related conditions or complications.If a specific strain is later identified, update the code accordingly.

** Use additional code to identify resistance to antimicrobial drugs (Z16.-) if applicable. If the infection is localized, code the localized infection first, followed by A41.2.

  • Payment Status: Active
  • Specialties:Infectious Disease, Critical Care Medicine, Emergency Medicine, Internal Medicine, General Surgery
  • Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office, Skilled Nursing Facility
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