Gram-negative sepsis, unspecified
ICD-10 A41.50 is a billable code used to indicate a diagnosis of gram-negative sepsis, unspecified.
Gram-negative sepsis is a severe systemic infection caused by gram-negative bacteria, which can lead to multi-organ failure and death if not promptly treated. The condition is characterized by the presence of bacteria in the bloodstream, triggering a systemic inflammatory response. Clinically, patients may present with fever, chills, tachycardia, hypotension, and altered mental status. The diagnosis is often made based on clinical signs, laboratory findings, and cultures that identify the causative organism. Gram-negative bacteria, such as Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa, are common culprits. Treatment typically involves aggressive fluid resuscitation, vasopressors, and broad-spectrum antibiotics, with a focus on antimicrobial stewardship to minimize resistance. Patients with gram-negative sepsis often require intensive care unit (ICU) management due to the potential for rapid deterioration and the need for close monitoring and supportive care. Early recognition and intervention are critical to improving outcomes in these patients.
Detailed documentation of the organism identified, clinical presentation, and treatment plan.
Patients presenting with fever and hypotension, requiring hospitalization and IV antibiotics.
Ensure that cultures are documented and results are linked to the diagnosis.
Comprehensive notes on patient monitoring, interventions, and response to treatment.
Patients in the ICU with severe sepsis requiring mechanical ventilation and vasopressors.
Document all supportive measures and their impact on patient outcomes.
Used for patients admitted with severe sepsis requiring extensive evaluation.
Detailed history, examination, and medical decision-making.
Critical care documentation must support the level of service billed.
A41.50 specifies gram-negative sepsis, while A41.9 is used for unspecified sepsis. A41.50 requires documentation of the gram-negative organism involved.
