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v1.0.0
ICD-10 Guide
DiagnosesEnterococcus Bacteremia

Enterococcus Bacteremia

ICD-10 Coding for Enterococcal Bacteremia(B95.2, A41.81, R78.81)

PRIMARY SPECIALTYInfectious Disease
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Enterococcus Bacteremia?
Essential facts and insights about Enterococcal Bacteremia

Key Clinical Considerations:

  • Fever, chills, and hypotension
  • Blood cultures positive for Enterococcus species
  • Signs of infection in the site of origin (e.g., urinary tract, endocarditis)

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history of recent antibiotic use or hospitalization
  • Identification of Enterococcus species in cultures
  • Clinical correlation with symptoms and laboratory findings

Coding Guidelines

Usage Guidelines & Examples

  • Follow guidelines for coding bacteremia versus sepsis.
  • Common errors include misidentifying the organism or not documenting the source of infection.

Code Exclusions

Important Exclusions

  • Other types of bacteremia (e.g., Staphylococcus, E. coli)
  • Alternative codes for Enterococcus infections in specific sites (e.g., urinary tract infections)

Related ICD-10 Codes

Primary Codes
A41.2
Enterococcus bacteremia
Ancillary Codes
R78.81
B95.2
Differential Codes
A41.81
A41.81
when systemic inflammatory response syndrome (SIRS) criteria are met with Enterococcus in blood.
R65.20
R65.20
when severe sepsis is present without shock.
A41.9
A41.9
when sepsis is present but the organism is unspecified.

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Infectious Disease

Specialty Applications

  • Immunocompromised patients, patients with chronic illnesses
  • Inpatient and outpatient settings, especially in hospitals

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

What are the documentation requirements?

Document the patient's clinical presentation, laboratory results, and any relevant history.

What are the billing considerations?

Ensure accurate coding based on the specific Enterococcus species and associated conditions.