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ICD-10 Guide
ICD-10 CodesA41.5

A41.5

Sepsis due to other Gram-negative organisms

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

Code Description

ICD-10 A41.5 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, and intra-abdominal infections. The clinical presentation may include fever, chills, tachycardia, hypotension, and altered mental status. Patients may exhibit signs of organ dysfunction, such as acute respiratory distress syndrome (ARDS), acute kidney injury, or septic shock. Management typically involves aggressive fluid resuscitation, broad-spectrum intravenous antibiotics, and supportive care in an intensive care unit (ICU) setting. Early identification and treatment are crucial to improving outcomes, as sepsis can rapidly progress to multi-organ failure. Antimicrobial stewardship is essential to ensure appropriate antibiotic selection and to minimize the development of resistance. Clinicians must be vigilant in monitoring for complications and adjusting treatment based on culture results and clinical response.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variety of potential Gram-negative organisms involved
  • Need for precise documentation of infection source
  • Differentiation from other types of sepsis
  • Potential for multi-organ dysfunction complicating coding

Audit Risk Factors

  • Inadequate documentation of the source of infection
  • Failure to document organ dysfunction
  • Misclassification of sepsis severity
  • Lack of clear treatment plans in medical records

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with fever and signs of systemic infection, requiring hospitalization.

Billing Considerations

Documentation must clearly indicate the causative organism and any resistance patterns.

Critical Care

Documentation Requirements

Comprehensive notes on patient monitoring, interventions, and response to treatment.

Common Clinical Scenarios

Management of septic patients in the ICU, including fluid resuscitation and vasopressor use.

Billing Considerations

Accurate recording of organ dysfunction and interventions is critical for coding.

Coding Guidelines

Inclusion Criteria

Use A41.5 When
  • According to ICD
  • 10 guidelines, A41
  • 5 should be used when the sepsis is confirmed to be due to Gram
  • negative organisms not classified elsewhere
  • Coders must ensure that the documentation supports the diagnosis of sepsis and includes details about the causative organism and any associated complications

Exclusion Criteria

Do NOT use A41.5 When
No specific exclusions found.

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.

Documentation Requirements

Comprehensive history, examination, and medical decision-making.

Specialty Considerations

Critical care specialists should ensure detailed documentation of the patient's condition and treatment plan.

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 ability to capture the nuances of different infections and their management. A41.5 provides a distinct code for sepsis due to Gram-negative organisms, which aids in tracking epidemiological trends and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of sepsis, improving the ability to capture the nuances of different infections and their management. A41.5 provides a distinct code for sepsis due to Gram-negative organisms, which aids in tracking epidemiological trends and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of sepsis, improving the ability to capture the nuances of different infections and their management. A41.5 provides a distinct code for sepsis due to Gram-negative organisms, which aids in tracking epidemiological trends and resource allocation.

Resources

Clinical References

  • •
    CDC Sepsis Guidelines

Coding & Billing References

  • •
    CDC Sepsis Guidelines

Frequently Asked Questions

What is the difference between A41.5 and A41.0?

A41.5 is specifically for sepsis due to other Gram-negative organisms, while A41.0 is for sepsis due to Escherichia coli. Accurate coding depends on identifying the specific organism responsible for the sepsis.