2025 ICD-10-CM code A41.4

Sepsis due to anaerobes.

Code A41.4 should be used when sepsis is documented as being caused by anaerobic bacteria.If the specific type of anaerobic bacteria is known, it should be documented, but the A41.4 code does not require further specification of the organism.If a patient has gas gangrene (A48.0), do not use code A41.4, as gas gangrene is a specific type of anaerobic infection classified separately.

Medical necessity for the diagnosis and treatment of sepsis due to anaerobes is established by the presence of clinical signs and symptoms of sepsis (e.g., fever, hypotension, tachycardia, organ dysfunction) in conjunction with laboratory confirmation of infection with anaerobic bacteria.The documentation should clearly support the diagnosis and the need for the specific treatment provided.

Clinicians should consider the patient's symptoms, medical history, and physical examination findings. Laboratory tests, including blood cultures, respiratory secretion analysis, skin specimen cultures, and vomit analysis, help identify the specific anaerobic bacteria. Treatment typically involves antibiotic therapy (oral or intravenous), along with supportive care like oxygen and intravenous fluids, if necessary.The severity of sepsis and the organs involved may influence the specific symptoms and treatment approach.

In simple words: Sepsis due to anaerobes is a serious infection where the body overreacts to harmful substances made by bacteria that don't need oxygen to live. These bacteria can enter the body through cuts, surgical procedures, or the respiratory, digestive, or reproductive tracts.

Sepsis caused by anaerobic bacteria (bacteria that grow without oxygen).This condition involves a systemic inflammatory response to toxins released by these bacteria into the bloodstream.

Example 1: A patient presents with fever, hypotension, tachycardia, and altered mental status after a recent abdominal surgery. Blood cultures reveal the presence of Bacteroides fragilis, confirming sepsis due to anaerobes., A patient with a diabetic foot ulcer develops fever, chills, and local signs of infection.Cultures from the ulcer grow anaerobic bacteria, indicating sepsis originating from the infected wound., A patient with aspiration pneumonia develops worsening respiratory distress and systemic signs of infection.Cultures from the respiratory tract identify anaerobic bacteria, confirming sepsis due to anaerobes as a complication of the pneumonia.

Documentation should include the type of anaerobic bacteria identified, the source of infection (if known), the patient's symptoms and signs of sepsis, and the treatment provided. Laboratory results confirming the presence of anaerobic bacteria are essential.Any underlying conditions or contributing factors should also be documented.

** Excludes1: gas gangrene (A48.0).Use additional code to identify resistance to antimicrobial drugs (Z16.-). Do not report sepsis of the newborn with code A41.4. Codes in category P36 should be used instead.

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