2025 ICD-10-CM code A41.9
(Active) Effective Date: N/A Certain infectious and parasitic diseases - Other bacterial diseases 1 Feed
Sepsis, unspecified organism.A systemic inflammatory response to an infection, where the causative organism is not identified.
Medical necessity for sepsis coding requires clear documentation of the systemic inflammatory response and the associated infection. Unspecified sepsis is coded when the causative organism is not identified despite investigation. This information is essential for appropriate treatment and resource allocation.
Providers diagnose sepsis based on symptoms, history, and physical findings. Laboratory tests of blood, urine, stool, skin, respiratory secretions, and vomit can help identify the bacteria. Treatment includes antibiotics and supportive measures like oxygen and intravenous fluids. Surgery may be necessary to clear the infection.
In simple words: Sepsis is a serious condition where the body overreacts to an infection in the blood. This code is used when the specific germ causing the infection isn't identified.
Sepsis due to an unspecified organism refers to a serious medical condition in which the body has a massive immune response to toxins released by bacteria into the bloodstream, which can lead to tissue damage, organ failure, and death. The provider does not specify the causative organism for sepsis.
Example 1: An 85-year-old male is admitted with fever, difficulty breathing, rapid heart rate, and altered mental status.Blood cultures are pending, and the physician documents "sepsis". Since the organism is unknown, A41.9 is used., A patient presents with symptoms suggestive of sepsis following a surgical procedure, but cultures are negative. In the absence of a confirmed pathogen, A41.9 is appropriate., A patient with a known urinary tract infection develops signs of a systemic inflammatory response, but blood cultures have not yet identified the organism. A41.9 is applied until (if) a specific pathogen is confirmed.
Documentation should include signs and symptoms of sepsis, such as fever, elevated heart rate, rapid breathing, and altered mental state. Lab results, including blood cultures, should also be documented. Any underlying conditions or procedures contributing to sepsis should be noted.
** Use additional code to identify resistance to antimicrobial drugs (Z16.-).
- Payment Status: Active
- Specialties:Infectious Disease, Critical Care, Emergency Medicine, Internal Medicine, Family Medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office, Skilled Nursing Facility, Nursing Facility