ICD-10 Guide

A41.52

Sepsis due to Pseudomonas

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/05/2025

Code Description

ICD-10 A41.52 is a billable code used to indicate a diagnosis of sepsis due to pseudomonas.

Key Diagnostic Point:

Sepsis due to Pseudomonas is a severe systemic infection characterized by the presence of Pseudomonas aeruginosa, a gram-negative bacterium, in the bloodstream. This condition is often associated with high morbidity and mortality rates, particularly in immunocompromised patients or those with underlying health conditions. The clinical presentation may include fever, chills, tachycardia, hypotension, and altered mental status, indicating a systemic inflammatory response. Diagnosis typically involves blood cultures, which may take time to yield results, complicating timely treatment. Management of sepsis due to Pseudomonas requires immediate initiation of broad-spectrum intravenous antibiotics, often followed by targeted therapy based on culture sensitivities. Patients may require intensive care unit (ICU) admission for close monitoring and supportive care, including fluid resuscitation and vasopressors. Antimicrobial stewardship is crucial to prevent resistance, as Pseudomonas infections can be difficult to treat due to its inherent resistance mechanisms. Early recognition and aggressive management are key to improving outcomes in patients with this life-threatening condition.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

Requires precise identification of the causative organism.
Differentiation from other types of sepsis is critical.
Documentation must support the severity of the condition.
Potential for multiple co-morbidities complicating the clinical picture.

Audit Risk Factors

Inadequate documentation of the organism causing sepsis.
Failure to document the severity of the patient's condition.
Misclassification of sepsis type (e.g., septic shock vs. sepsis).
Inconsistent coding of associated conditions.

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed microbiological data, treatment response, and patient history.

Common Clinical Scenarios

Patients with immunosuppression, chronic lung disease, or recent surgeries.

Billing Considerations

Ensure that the causative organism is clearly documented and that treatment plans are outlined.

Critical Care

Documentation Requirements

Comprehensive ICU notes, including vital signs, treatment interventions, and patient progress.

Common Clinical Scenarios

Patients requiring mechanical ventilation or vasopressor support.

Billing Considerations

Document all interventions and responses to treatment to support the severity of illness.

Coding Guidelines

Inclusion Criteria

Use A41.52 When

Follow the official ICD
CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation
Include any relevant laboratory results and treatment plans

Exclusion Criteria

Do NOT use A41.52 When

Exclude codes that do not specify Pseudomonas as the causative agent

Related CPT Codes

87040CPT Code

Culture, bacterial, any source

Clinical Scenario

Used when blood cultures are performed to identify Pseudomonas.

Documentation Requirements

Document the source of the culture and results.

Specialty Considerations

Infectious disease specialists should ensure cultures are obtained before antibiotics are administered.

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 the causative organism, which aids in better tracking of infection rates and outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of sepsis, including the identification of the causative organism, which aids in better tracking of infection rates and outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of sepsis, including the identification of the causative organism, which aids in better tracking of infection rates and outcomes.

Resources

Clinical References

•
CDC Sepsis Guidelines

Coding & Billing References

•
CDC Sepsis Guidelines

Frequently Asked Questions

What is the significance of coding A41.52?

Coding A41.52 accurately reflects the severity and specific etiology of the patient's sepsis, which is crucial for appropriate treatment and resource allocation.

ICD-10 A41.52 is a billable code used to indicate a diagnosis of sepsis due to pseudomonas.