2025 ICD-10-CM code A41
(Active) Effective Date: N/A Infectious and parasitic diseases - Other bacterial diseases Certain infectious and parasitic diseases Feed
Other sepsis
Medical necessity for the treatment of sepsis (A41) is established by the presence of clinical indicators of a systemic infection with organ dysfunction. Documentation must support the severity of the infection and the need for medical intervention.
Physicians must identify the underlying cause of sepsis, assess organ function, administer appropriate antimicrobials and supportive care (e.g., IV fluids, vasopressors), and monitor the patient's response to treatment. Documentation should include the suspected or confirmed source of infection, clinical findings supporting the diagnosis of sepsis, and all treatment interventions.
In simple words: Sepsis, also known as blood poisoning, is a severe medical condition where the body's immune system overreacts to an infection, potentially leading to organ damage and death. This code signifies sepsis caused by a bacteria or organism not specifically identified by other codes.
Sepsis due to other specified organisms. This code should be used for sepsis caused by organisms not classified elsewhere in the ICD-10-CM.
Example 1: A 70-year-old patient presents with fever, altered mental status, and hypotension following a urinary tract infection. Blood cultures are positive for an unusual bacterial strain, and the patient is diagnosed with sepsis due to this organism. Code A41 is used., A patient with a compromised immune system develops sepsis following a skin infection. The causative organism is identified as a rare fungus. A41 would be applied as the cause is a fungus not specified elsewhere., A patient undergoing chemotherapy develops a bloodstream infection with an atypical bacteria. They exhibit signs and symptoms of sepsis. A41 is used since the causative agent is a less common bacteria, not categorized under other sepsis codes.
Documentation should include evidence of infection (e.g., positive cultures, imaging findings), signs and symptoms of sepsis (e.g., fever, tachycardia, hypotension, altered mental status, elevated lactate), and the specific organism responsible, if identified.
- Specialties:Infectious disease, critical care medicine, internal medicine, emergency medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital