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ICD-10 Guide
ICD-10 CodesA41.4

A41.4

Sepsis due to other Gram-negative organisms

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

Code Description

ICD-10 A41.4 is a billable code used to indicate a diagnosis of sepsis due to other gram-negative organisms.

Key Diagnostic Point:

Sepsis due to other Gram-negative organisms is a severe systemic response to infection characterized by the presence of Gram-negative bacteria in the bloodstream. This condition can arise from various sources, including urinary tract infections, pneumonia, or intra-abdominal infections. The clinical presentation often includes fever, tachycardia, hypotension, and altered mental status, indicating a life-threatening condition requiring immediate medical intervention. Patients may present with signs of organ dysfunction, such as acute respiratory distress syndrome (ARDS) or acute kidney injury (AKI). Management typically involves aggressive fluid resuscitation, broad-spectrum intravenous antibiotics, and supportive care in an intensive care unit (ICU) setting. Antimicrobial stewardship is crucial to ensure appropriate antibiotic selection, minimize resistance, and optimize patient outcomes. Early recognition and treatment are vital to reduce morbidity and mortality associated with sepsis due to Gram-negative organisms.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variety of potential Gram-negative organisms causing sepsis
  • Need for precise documentation of the source of infection
  • Differentiation from other types of sepsis (e.g., Gram-positive, fungal)
  • Potential for multiple organ dysfunction syndrome (MODS) complicating coding

Audit Risk Factors

  • Inadequate documentation of the source of infection
  • Failure to document organ dysfunction or severity of sepsis
  • Misclassification of sepsis type (e.g., Gram-positive vs. Gram-negative)
  • Lack of clarity in the clinical narrative regarding treatment and response

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

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

Common Clinical Scenarios

Patients with complicated urinary tract infections leading to sepsis.

Billing Considerations

Documentation must specify the organism and source of infection.

Critical Care Medicine

Documentation Requirements

Comprehensive assessment of organ function, treatment protocols, and response to therapy.

Common Clinical Scenarios

Patients admitted to the ICU with septic shock.

Billing Considerations

Clear documentation of interventions and monitoring parameters is essential.

Coding Guidelines

Inclusion Criteria

Use A41.4 When
  • According to ICD
  • CM guidelines, A41
  • 4 should be used when the sepsis is specifically due to other Gram
  • negative organisms
  • Coders must ensure that the documentation supports the diagnosis of sepsis and identifies the causative organism

Exclusion Criteria

Do NOT use A41.4 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 requiring extensive evaluation.

Documentation Requirements

Comprehensive documentation of history, examination, and medical decision-making.

Specialty Considerations

Critical care specialists must document the severity of illness.

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. This specificity improves data accuracy and enhances the ability to track sepsis-related outcomes and resource utilization.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of sepsis, including the identification of causative organisms. This specificity improves data accuracy and enhances the ability to track sepsis-related outcomes and resource utilization.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of sepsis, including the identification of causative organisms. This specificity improves data accuracy and enhances the ability to track sepsis-related outcomes and resource utilization.

Resources

Clinical References

  • •
    CDC Sepsis Guidelines

Coding & Billing References

  • •
    CDC Sepsis Guidelines

Frequently Asked Questions

What documentation is needed to support the use of A41.4?

Documentation must include the identification of the Gram-negative organism, the source of infection, and evidence of organ dysfunction or severe sepsis.