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ICD-10 Guide
ICD-10 CodesA41.01

A41.01

Sepsis due to Methicillin susceptible Staphylococcus aureus

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

Code Description

ICD-10 A41.01 is a billable code used to indicate a diagnosis of sepsis due to methicillin susceptible staphylococcus aureus.

Key Diagnostic Point:

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. A41.01 specifically refers to sepsis resulting from Methicillin susceptible Staphylococcus aureus (MSSA), a common bacterium that can lead to severe infections. MSSA is known for its ability to cause a range of infections, including skin infections, pneumonia, and bloodstream infections. In cases of sepsis, the bacteria enter the bloodstream, triggering a systemic inflammatory response that can lead to multi-organ failure. Patients with sepsis often require intensive care unit (ICU) management, including fluid resuscitation, vasopressors, and broad-spectrum antibiotics. The timely identification and treatment of sepsis are critical, as delays can significantly increase morbidity and mortality. Antimicrobial stewardship is essential in managing sepsis due to MSSA, as inappropriate antibiotic use can lead to resistance and complicate treatment. Clinicians must balance the need for immediate intervention with the principles of stewardship to ensure effective and responsible use of antibiotics.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between sepsis and other infections
  • Identifying the specific organism causing sepsis
  • Understanding the severity of the patient's condition
  • Documentation of organ dysfunction criteria

Audit Risk Factors

  • Inadequate documentation of the organism
  • Failure to document organ dysfunction
  • Incorrect coding of sepsis severity
  • Lack of clarity in clinical notes regarding treatment

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed microbiological data, clinical presentation, and treatment response.

Common Clinical Scenarios

Patients presenting with fever, chills, and hypotension due to MSSA infections.

Billing Considerations

Ensure that the organism is clearly identified in the documentation to support the use of A41.01.

Critical Care

Documentation Requirements

Comprehensive notes on organ dysfunction, treatment protocols, and response to interventions.

Common Clinical Scenarios

Patients requiring ICU admission for severe sepsis or septic shock.

Billing Considerations

Document all interventions and their outcomes to justify the severity of the condition.

Coding Guidelines

Inclusion Criteria

Use A41.01 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation
  • Include evidence of organ dysfunction and the specific organism responsible for sepsis

Exclusion Criteria

Do NOT use A41.01 When
No specific exclusions found.

Related CPT Codes

99223CPT Code

Initial hospital care, typically 70 minutes or more

Clinical Scenario

Used for patients admitted with sepsis due to MSSA.

Documentation Requirements

Comprehensive history, examination, and medical decision-making.

Specialty Considerations

Critical care documentation must reflect the severity of the patient's condition.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of sepsis, improving the accuracy of data collection and reimbursement. A41.01 provides a clear distinction between MSSA and other organisms, enhancing clinical understanding and treatment protocols.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of sepsis, improving the accuracy of data collection and reimbursement. A41.01 provides a clear distinction between MSSA and other organisms, enhancing clinical understanding and treatment protocols.

Reimbursement & Billing Impact

reimbursement. A41.01 provides a clear distinction between MSSA and other organisms, enhancing clinical understanding and treatment protocols.

Resources

Clinical References

  • •
    CDC Sepsis Guidelines

Coding & Billing References

  • •
    CDC Sepsis Guidelines

Frequently Asked Questions

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

Identifying the organism is crucial for appropriate treatment and for accurate coding, as different organisms may require different management strategies and have different implications for patient outcomes.