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2025 ICD-10-CM code P36.2

Sepsis of the newborn caused by Staphylococcus aureus.

Code first the underlying systemic infection (P36.2). Additional codes are required for severe sepsis (R65.2-) and to specify any acute organ dysfunction.

Medical necessity is established by the presence of clinical symptoms and laboratory confirmation of Staphylococcus aureus bacteremia in a newborn. Treatment is necessary to prevent life-threatening complications and to improve outcomes.

The clinical responsibility involves diagnosing and managing the neonatal sepsis, including administering antibiotics, monitoring vital signs, providing respiratory support if needed, and managing organ dysfunction. Close collaboration with neonatology and infectious disease specialists might be necessary.

IMPORTANT:Related codes include other types of neonatal sepsis (P36.0-P36.9)and codes for severe sepsis (R65.2-) and associated organ dysfunctions.Use additional codes to specify the affected organs.

In simple words: This code means a newborn baby has a serious bloodstream infection caused by staph bacteria.The baby might be very sick and need extra medical care.

This code is used to classify sepsis in a newborn infant specifically caused by Staphylococcus aureus bacteria.It indicates a systemic infection, involving the bloodstream, and requires additional codes to specify severe sepsis (R65.2-) and associated organ dysfunctions if present.The infection's origin could be in utero, during delivery, or within the first 28 days post-birth.This code is for newborn records only; never use it on maternal records.

Example 1: A newborn presents with lethargy, fever, respiratory distress, and poor feeding within 24 hours of birth. Blood cultures reveal Staphylococcus aureus.The diagnosis is neonatal sepsis due to Staphylococcus aureus (P36.2)., A 10-day-old infant develops signs of sepsis including hypotension, tachycardia, and decreased urine output.Blood cultures identify methicillin-resistant Staphylococcus aureus (MRSA).The code P36.2 is used, along with additional codes specifying MRSA and severe sepsis., A preterm infant shows signs of sepsis during the first week of life.A positive blood culture for Staphylococcus aureus is obtained.The clinician codes P36.2, and further codes might be added to reflect prematurity and any organ dysfunction.

Complete history and physical examination documenting symptoms suggestive of sepsis.Results of blood cultures identifying Staphylococcus aureus.Documentation of vital signs, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.Laboratory findings of organ dysfunction (e.g., elevated creatinine, decreased urine output, abnormal liver function tests).Treatment administered, including antibiotics and supportive care.

** This code is exclusively for use in newborn records and should not be applied to maternal records.The use of additional codes is crucial to accurately reflect the severity and associated organ dysfunctions.

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