2025 ICD-10-CM code A49.9
(Active) Effective Date: N/A Infectious and Parasitic Diseases - Other bacterial diseases Certain infectious and parasitic diseases Feed
Bacterial infection, unspecified.
Medical necessity for A49.9 is established by the presence of signs and symptoms of a bacterial infection, supported by clinical findings and/or laboratory results.The documentation must clearly indicate why a more specific diagnosis cannot be determined at the time of coding.
Clinicians should conduct thorough examinations, including laboratory tests (blood, urine, cultures), to identify the source and type of infection if possible.Treatment may include antibiotics and supportive care, depending on the patient's symptoms and overall health. Clinicians are responsible for documenting the rationale for using this unspecified code and should strive to provide a more specific diagnosis if further information becomes available.
In simple words: This code indicates a bacterial infection where the specific type or location isn't identified.It's used when tests confirm a bacterial infection, but further details are unknown.
Bacterial infection, unspecified.Excludes1: bacteremia NOS (R78.81)
Example 1: A patient presents with fever, fatigue, and body aches. Blood tests reveal an elevated white blood cell count, suggesting a bacterial infection, but the specific location and bacteria type are not identified yet. A49.9 is used until further testing is completed., A patient with a confirmed bacterial infection from a wound culture develops systemic symptoms like fever and chills.The initial culture did not pinpoint the specific bacteria, and while awaiting further results, A49.9 is used to document the systemic infection., A patient with a history of intravenous drug use presents with fever and malaise.Blood cultures are drawn, and the patient is started on broad-spectrum antibiotics for presumed bacteremia. If the blood cultures do not identify a specific bacteria, A49.9 would be appropriate.
Documentation should include evidence of a bacterial infection such as positive lab results (e.g., blood culture, urine culture, wound culture), elevated white blood cell count, or clinical findings suggestive of infection (e.g., fever, inflammation). It is also crucial to document why a more specific code cannot be assigned and any efforts made to obtain a definitive diagnosis.
** It is essential to differentiate between the terms 'unspecified' and 'not otherwise specified (NOS).' 'Unspecified' means that no further information is available to assign a more precise code, whereas 'NOS' signifies that a specific code exists for the condition, but the provider has not documented it. Always choose the most specific code possible based on the documented information.
- Payment Status: Active
- Specialties:Infectious Disease, Internal Medicine, Family Medicine, Emergency Medicine
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital, Office, Independent Clinic, Federally Qualified Health Center