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ICD-10 Guide
ICD-10 CodesA41.0

A41.0

Sepsis due to Staphylococcus aureus

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 A41.0 is a billable code used to indicate a diagnosis of sepsis due to staphylococcus aureus.

Key Diagnostic Point:

Sepsis due to Staphylococcus aureus is a severe systemic infection characterized by the presence of Staphylococcus aureus bacteria in the bloodstream, leading to a dysregulated host response. This condition can arise from various sources, including skin infections, pneumonia, or surgical site infections. Clinically, patients may present with fever, chills, tachycardia, hypotension, and altered mental status. The diagnosis of sepsis requires a high index of suspicion, particularly in patients with risk factors such as immunosuppression, recent surgery, or chronic illnesses. Laboratory findings may include elevated white blood cell counts, positive blood cultures for Staphylococcus aureus, and signs of organ dysfunction. Management typically involves prompt initiation of broad-spectrum intravenous antibiotics, aggressive fluid resuscitation, and supportive care in an intensive care unit (ICU) setting. Antimicrobial stewardship is crucial to optimize treatment and minimize resistance development. Early recognition and intervention are vital to improve outcomes in patients with sepsis due to Staphylococcus aureus.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Differentiating between sepsis and other severe infections
  • Need for precise documentation of the source of infection
  • Variability in clinical presentation among patients
  • Potential for multiple co-morbid conditions complicating the diagnosis

Audit Risk Factors

  • Inadequate documentation of the source of infection
  • Failure to document organ dysfunction
  • Inconsistent use of sepsis criteria
  • Lack of clarity in the clinical decision-making process

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed history of infection, laboratory results, and treatment response.

Common Clinical Scenarios

Patients presenting with fever and suspected sepsis, particularly those with recent surgeries or chronic illnesses.

Billing Considerations

Documentation must clearly indicate the source of infection and any comorbidities affecting treatment.

Critical Care

Documentation Requirements

Comprehensive ICU admission notes, including vital signs, lab results, and treatment plans.

Common Clinical Scenarios

Management of septic shock in critically ill patients requiring intensive monitoring and intervention.

Billing Considerations

Accurate documentation of organ failure and response to treatment is essential for coding.

Coding Guidelines

Inclusion Criteria

Use A41.0 When
  • According to ICD
  • 10 guidelines, A41
  • 0 should be used when the sepsis is specifically due to Staphylococcus aureus
  • It is essential to document the clinical criteria for sepsis and any associated organ dysfunction

Exclusion Criteria

Do NOT use A41.0 When
  • Exclusion criteria include cases where the organism is not identified or when sepsis is due to another pathogen

Related CPT Codes

99223CPT Code

Initial hospital care, high complexity

Clinical Scenario

Used for the initial evaluation and management of a patient with sepsis in the hospital setting.

Documentation Requirements

Comprehensive history, examination, and medical decision-making.

Specialty Considerations

Critical care documentation must reflect the severity of illness and complexity of care.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of sepsis, including the identification of causative organisms like Staphylococcus aureus. This specificity enhances data accuracy and improves patient care through better tracking of infection trends.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of sepsis, including the identification of causative organisms like Staphylococcus aureus. This specificity enhances data accuracy and improves patient care through better tracking of infection trends.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of sepsis, including the identification of causative organisms like Staphylococcus aureus. This specificity enhances data accuracy and improves patient care through better tracking of infection trends.

Resources

Clinical References

  • •
    CDC Sepsis Guidelines

Coding & Billing References

  • •
    CDC Sepsis Guidelines

Frequently Asked Questions

What is the importance of identifying the causative organism in sepsis?

Identifying the causative organism is crucial for appropriate antibiotic therapy, which can significantly impact patient outcomes and reduce the risk of antibiotic resistance.