🧬ICD-10-CM Code: A41.9

Quick Reference

Code: A41.9
Short Description: Sepsis, unspecified organism
Category: A41 - Other sepsis
Chapter: A - Certain infectious and parasitic diseases (A00-B99)
HIPAA Valid: βœ… Yes (valid for billing/transactions)
HCC Status: βœ… YES - HCC 2 (High risk, significant RAF impact)


Description

Short Description

Systemic inflammatory response syndrome (SIRS) with documented or suspected infection when the causative organism is not specified or identified.

Full Description

A41.9 represents sepsis without specification of the causative organism. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. This code is used when:

  • The causative organism has not yet been identified
  • Culture results are pending or negative despite clinical sepsis
  • Documentation indicates sepsis but doesn’t specify the pathogen
  • The organism doesn’t fit into other more specific A41 categories

Clinical Definition: Sepsis requires evidence of infection PLUS evidence of organ dysfunction (typically measured by Sequential Organ Failure Assessment [SOFA] score increase of β‰₯2 points).

Key Features:

  • Life-threatening condition with high mortality
  • Requires prompt recognition and treatment
  • May progress to severe sepsis or septic shock
  • Often necessitates ICU-level care
  • Significant resource utilization

⚠️ CRITICAL CODING ALERT

Sepsis Coding Rules (ICD-10-CM Guidelines)

ALWAYS follow these sequencing rules:

  1. Underlying condition first - If sepsis is due to postprocedural infection, code the complication first (T80.2-, T81.4-, etc.)
  2. Sepsis code second - A41.9 or more specific sepsis code
  3. Severe sepsis - Add R65.20 (severe sepsis without septic shock) or R65.21 (severe sepsis with septic shock)
  4. Organ dysfunction - Code any associated acute organ dysfunction
  5. Septic shock - If present, code R65.21 (never use R57.9 for septic shock)

Quick Sequencing Guide

Scenario 1: Sepsis without complications
Primary: A41.9 (or specific organism if known)

Scenario 2: Severe sepsis with organ dysfunction
Primary: A41.9 (or underlying condition if postprocedural)
Secondary: R65.20 (severe sepsis without shock)
Additional: Code organ dysfunction (e.g., N17.9 for AKI)

Scenario 3: Septic shock
Primary: A41.9 (or underlying condition if postprocedural)
Secondary: R65.21 (severe sepsis WITH septic shock)
Additional: Code organ dysfunction

Scenario 4: Postoperative sepsis
Primary: T81.44XA (Sepsis following a procedure, initial)
Secondary: A41.9 (or specific organism)
Additional: R65.20 or R65.21 if severe/shock

Hierarchical Classification

ICD-10-CM Structure:

A00-B99: Certain infectious and parasitic diseases
  └─ A30-A49: Other bacterial diseases
      └─ A41: Other sepsis
          β”œβ”€ A41.0x: Sepsis due to Staphylococcus aureus
          β”‚   β”œβ”€ A41.01: MSSA sepsis
          β”‚   └─ A41.02: MRSA sepsis
          β”œβ”€ A41.1: Sepsis due to other specified staphylococcus
          β”œβ”€ A41.2: Sepsis due to unspecified staphylococcus
          β”œβ”€ A41.3: Sepsis due to Hemophilus influenzae
          β”œβ”€ A41.4: Sepsis due to anaerobes
          β”œβ”€ A41.5x: Sepsis due to Gram-negative organisms
          β”‚   β”œβ”€ A41.50: Gram-negative sepsis, unspecified
          β”‚   β”œβ”€ A41.51: E. coli sepsis
          β”‚   β”œβ”€ A41.52: Pseudomonas sepsis
          β”‚   β”œβ”€ A41.53: Serratia sepsis
          β”‚   β”œβ”€ A41.54: Acinetobacter baumannii sepsis
          β”‚   └─ A41.59: Other Gram-negative sepsis
          β”œβ”€ A41.8x: Other specified sepsis
          β”‚   β”œβ”€ A41.81: Enterococcus sepsis
          β”‚   └─ A41.89: Other specified sepsis
          └─ A41.9: Sepsis, UNSPECIFIED organism ⬅️ You are here

Specific Organism Sepsis Codes (A41.xx)

CodeDescriptionUse When
A41.01MSSA sepsisMethicillin-sensitive staph aureus confirmed
A41.02MRSA sepsisMethicillin-resistant staph aureus confirmed
A41.2Unspecified staph sepsisStaph species confirmed but sensitivity unknown
A41.3H. influenzae sepsisHemophilus influenzae confirmed
A41.4Anaerobic sepsisAnaerobic organism confirmed
A41.50Gram-negative sepsis, unspecifiedGram-negative organism, species unknown
A41.51E. coli sepsisE. coli confirmed
A41.52Pseudomonas sepsisPseudomonas confirmed
A41.81Enterococcus sepsisEnterococcus confirmed
A41.89Other specified sepsisOther identified organism not elsewhere classified

Severe Sepsis Codes (ALWAYS use with A41.9)

CodeDescriptionWhen to Add
R65.20Severe sepsis without septic shockSepsis + acute organ dysfunction, no shock
R65.21Severe sepsis WITH septic shockSepsis + organ dysfunction + hypotension requiring vasopressors

Common Organ Dysfunction Codes (use with severe sepsis)

CodeDescription
N17.9Acute kidney injury, unspecified
N17.0Acute kidney failure with tubular necrosis
J96.00Acute respiratory failure, unspecified
J96.01Acute respiratory failure with hypoxia
J96.02Acute respiratory failure with hypercapnia
K72.00Acute and subacute hepatic failure without coma
D65Disseminated intravascular coagulation
I95.9Hypotension, unspecified
G93.41Metabolic encephalopathy

Postprocedural Sepsis (sequence BEFORE A41.9)

CodeDescription
T81.44XASepsis following a procedure, initial encounter
T81.44XDSepsis following a procedure, subsequent encounter
O85Puerperal sepsis
T80.211ABloodstream infection due to central venous catheter, initial
CodeDescription
A40.9Streptococcal sepsis, unspecified
A02.1Salmonella sepsis
B37.7Candidal sepsis
A32.7Listerial sepsis
R78.81Bacteremia (NOT sepsis - different condition)

HCC (Hierarchical Condition Category) Information

βœ… HCC STATUS: YES - This is a HIGH-VALUE HCC Code

HCC Mapping:

ModelHCC CategoryDescriptionRAF Impact
CMS-HCC V24HCC 2Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/ShockHigh
CMS-HCC V28HCC 2SepsisHigh
HHS-HCCHCC 2Septicemia/SepsisHigh

Risk Adjustment Factor (RAF) Impact

  • Significant RAF increase (typically 0.5 - 1.5+ points depending on model and patient demographics)
  • One of the highest-weighted condition categories
  • Major impact on capitated payment rates
  • Critical for accurate risk stratification

HCC Coding Requirements

To capture HCC for risk adjustment:

  1. βœ… Must be documented by physician/qualified provider
  2. βœ… Must be clinically supported (positive cultures, clinical sepsis criteria)
  3. βœ… Must be treated or monitored during the encounter
  4. βœ… Must be coded at least once per calendar year for chronic conditions
  5. βœ… Documentation must support the diagnosis (evidence of infection + SIRS criteria or organ dysfunction)

HCC Hierarchy

  • HCC 2 (Sepsis) is a separate category - does NOT hierarchy with other infection codes
  • Sepsis captures higher acuity than simple infections
  • Both sepsis AND site-specific infection can be coded (e.g., A41.9 + pneumonia)

RVU Information

Note: RVUs (Relative Value Units) and wRVUs (work RVUs) apply to CPT procedure codes, not ICD-10 diagnosis codes.

  • ICD-10 codes (like A41.9) are diagnosis codes for documenting medical conditions
  • CPT codes are procedure codes with associated RVU values for physician payment
  • A41.9 itself has no RVU value

DRG Impact (Hospital Reimbursement)

A41.9 DOES significantly impact hospital reimbursement through DRG assignment:

Common DRGs with Sepsis:

DRGDescriptionRelative Weight
870Septicemia or severe sepsis w/o MV >96 hours w MCC~1.7-2.0
871Septicemia or severe sepsis w/o MV >96 hours w/o MCC~0.9-1.1
853Infectious & parasitic diseases w O.R. procedure w MCC~3.5-4.5

Note: DRG weights vary by facility and year. Sepsis as a complicating condition (CC) or major complicating condition (MCC) significantly increases reimbursement for any principal diagnosis.

For RVU information related to procedures performed, refer to the specific CPT codes used (see CPT section below).


Common Associated CPT Codes

Evaluation & Management (Most Common)

CPT CodeDescriptionTypical Setting
99221-99223Initial hospital care, per dayAdmission for sepsis
99231-99233Subsequent hospital care, per dayDaily sepsis management
99238-99239Hospital discharge day managementSepsis recovery discharge
99291Critical care, first 30-74 minutesICU/septic shock management
99292Critical care, each additional 30 minutesExtended critical care
99223Initial hospital care, high complexitySevere sepsis admission
99233Subsequent hospital care, high complexityComplicated sepsis course

Emergency Department

CPT CodeDescription
99284ED visit, high complexity
99285ED visit, high complexity with significant threat to life

Diagnostic Procedures

CPT CodeDescriptionPurpose
36415Routine venipunctureBlood cultures
87040Blood culture, aerobicOrganism identification
87070Culture, bacterial, any sourceSource identification
87184Susceptibility testing, disk methodAntibiotic sensitivity
87186Susceptibility testing, MIC methodAntibiotic sensitivity
87076Anaerobic cultureAnaerobic organism identification
85025Complete blood count (CBC) with differentialMonitor WBC, bands
80053Comprehensive metabolic panelOrgan function assessment
82947Glucose (quantitative)Dysglycemia monitoring
83735MagnesiumElectrolyte monitoring
85610Prothrombin time (PT)Coagulation assessment
85730Thromboplastin time, partial (PTT)Coagulation assessment
82803Blood gases, any combinationOxygenation/ventilation status
83520Immunoassay, procalcitoninSepsis biomarker

Interventional Procedures

CPT CodeDescriptionWhen Used
36556Insertion of non-tunneled central catheter (age <5)Central access for critically ill
36558Insertion of non-tunneled central catheter (age β‰₯5)Central access
31500Intubation, endotracheal, emergencyRespiratory failure
94002Ventilation assist and management, initial dayMechanical ventilation
94003Ventilation assist, subsequent daysOngoing ventilator management
36620Arterial catheterization/cannulationArterial line for hemodynamic monitoring
93503Insertion/placement of Swan-Ganz catheterAdvanced hemodynamic monitoring

Imaging (Source Identification)

CPT CodeDescription
71046Chest X-ray, 2 views
71250CT chest without contrast
74150CT abdomen without contrast
74176CT abdomen and pelvis without contrast
76700Ultrasound, abdominal, complete
76775Ultrasound, retroperitoneal (kidneys)

Clinical Considerations

SIRS Criteria (2 or more required for clinical diagnosis)

  1. ❌ Temperature >38°C (100.4°F) or <36°C (96.8°F) Note: SIRS criteria less emphasized in Sepsis-3 definition
  2. ❌ Heart rate >90 bpm
  3. ❌ Respiratory rate >20/min or PaCO2 <32 mmHg
  4. ❌ WBC >12,000 or <4,000 cells/mm³ or >10% bands

Modern Sepsis-3 Criteria (Preferred)

Sepsis = Infection + Organ Dysfunction

  • qSOFA (Quick SOFA - screening tool):
    • Respiratory rate β‰₯22/min
    • Altered mentation (GCS <15)
    • Systolic BP ≀100 mmHg
  • SOFA Score increase β‰₯2 points (definitive organ dysfunction assessment)

Septic Shock Criteria

Sepsis PLUS:

  1. Vasopressor requirement to maintain MAP β‰₯65 mmHg
  2. Serum lactate >2 mmol/L despite adequate fluid resuscitation

Documentation Requirements for A41.9

Minimum Required Documentation:

  1. βœ… Physician documentation of β€œsepsis” (mandatory)
  2. βœ… Evidence of infection (clinical or culture-proven)
  3. βœ… Evidence of systemic response or organ dysfunction

Optimal Documentation Includes:

  • Specific term β€œsepsis” in provider documentation
  • Suspected or confirmed source of infection
  • Clinical signs of infection (fever, hypothermia, leukocytosis, etc.)
  • Evidence of organ dysfunction (if severe sepsis)
  • Lactate level
  • Blood pressure/vasopressor requirements (if shock)
  • Culture results (when available)
  • Antibiotic therapy initiated
  • Fluid resuscitation documented
  • SOFA or qSOFA score (helpful but not required)

Query Opportunities

Query the provider if documentation shows:

  • β€œSIRS” without mention of infection or sepsis
  • β€œBacteremia” without sepsis terminology
  • Clinical sepsis without physician documentation
  • Organ dysfunction without β€œsevere sepsis” or shock documented
  • Sepsis with unclear timing (present on admission vs hospital-acquired)

Differential Diagnosis

Consider and rule out:

  • SIRS without infection (trauma, pancreatitis, burns)
  • Bacteremia without sepsis (positive culture, no systemic response)
  • Localized infection without systemic involvement
  • Non-infectious causes of shock (cardiogenic, hypovolemic, anaphylactic)

Common Sepsis Sources

SourceAssociated ICD-10
PneumoniaJ15.9, J18.9
Urinary tractN39.0
Skin/soft tissueL03.90
Intra-abdominalK65.9, K57.20
Bloodstream (CLABSI)T80.211A
Bone/jointM86.9
UnknownCode A41.9 only

Coding Guidelines & Best Practices

ICD-10-CM Official Guidelines for Sepsis

1. Code Assignment

  • A41.9 should only be used when the organism is truly unknown
  • If organism is known, use specific code (A41.01, A41.51, etc.)
  • Always attempt to obtain organism identification from cultures

2. Negative or Inconclusive Cultures

  • Sepsis can be coded with negative cultures if clinically supported
  • Provider must document β€œsepsis” regardless of culture results
  • Clinical diagnosis of sepsis is acceptable

3. Sepsis Sequencing

Principal Diagnosis Rules:

  • Sepsis is principal diagnosis UNLESS:
    • Due to postprocedural infection (code T81.44XA first)
    • Meets criteria for β€œprincipal diagnosis” of another condition

Example Sequencing:

SCENARIO A: Patient admitted with pneumonia, develops sepsis
Principal: J18.9 (Pneumonia)
Secondary: A41.9 (Sepsis)

SCENARIO B: Patient admitted FOR sepsis
Principal: A41.9 (Sepsis)
Secondary: J18.9 (Pneumonia - source)

SCENARIO C: Post-op day 3 patient develops sepsis
Principal: T81.44XA (Postprocedural sepsis)
Secondary: A41.9 (Sepsis, unspecified organism)

4. Severe Sepsis

  • ALWAYS code R65.20 or R65.21 when documentation states β€œsevere sepsis” or β€œseptic shock”
  • Code associated acute organ dysfunction
  • Severe sepsis can be present on admission OR develop during hospitalization

5. Septic Shock

  • Septic shock = severe sepsis with circulatory failure
  • Code R65.21 (severe sepsis WITH septic shock)
  • Do NOT use R57.9 for septic shock
  • Must have both sepsis code AND R65.21

6. Sepsis and Severe Sepsis as Secondary Diagnoses

  • Can be coded as secondary if patient admitted for another condition but also has sepsis
  • Follow sequencing rules based on circumstances of admission

7. Sepsis Due to Postprocedural Infection

  • Assign T81.44- as principal diagnosis
  • Then assign A41.9 or specific organism code
  • Use R65.20 or R65.21 if severe/shock

Coding Tips

βœ… DO:

  • Use provider’s documentation of β€œsepsis” - required for code assignment
  • Code the most specific organism when known
  • Always add R65.20 or R65.21 for severe sepsis/shock
  • Code all associated organ dysfunction
  • Verify timing (POA vs hospital-acquired) for quality measures
  • Query for organism if cultures are positive but not documented
  • Document and code the source of infection when known

❌ DON’T:

  • Code sepsis without physician documentation of β€œsepsis”
  • Use A41.9 if organism is specified elsewhere in the record
  • Confuse β€œbacteremia” with β€œsepsis” (different conditions)
  • Use β€œSIRS” alone to code sepsis
  • Forget to code severe sepsis (R65.20/R65.21) when documented
  • Use R57.9 for septic shock (use R65.21 instead)
  • Code sepsis based solely on SIRS criteria without infection

Present on Admission (POA) Indicator

Critical for Quality Measures:

  • Y = Present at time of inpatient admission
  • N = Developed after admission (hospital-acquired)
  • Hospital-acquired sepsis affects quality metrics and reimbursement
  • Accurate POA reporting is mandatory

Reimbursement & Quality Measures

Financial Impact

DRG Impact:

  • Sepsis as principal diagnosis: DRG 870/871 (Septicemia)
  • Sepsis as CC/MCC: Increases DRG weight for other principal diagnoses
  • Average reimbursement increase: 15,000+ depending on severity

HCC Impact:

  • RAF increase: ~0.5-1.5 points
  • Annual per-member-per-month (PMPM) impact: Significant
  • Medicare Advantage plans: High value for risk adjustment

Quality Measures Affected

CMS Core Measures:

  • SEP-1: Severe Sepsis and Septic Shock Early Management Bundle
    • Blood cultures before antibiotics
    • Broad-spectrum antibiotics within 3 hours (ED) or 1 hour (ICU)
    • Lactate measurement
    • Fluid resuscitation (30 mL/kg for hypotension or lactate β‰₯4)
    • Vasopressors for persistent hypotension
    • Repeat lactate if initially elevated

Hospital-Acquired Conditions (HAC):

  • Hospital-acquired sepsis is a never event in some contexts
  • POA accuracy is critical
  • Affects value-based purchasing scores

Prior Authorization

  • Usually not required for admission
  • Some payers may require for extended ICU stays
  • Antibiotic choices may require stewardship approval

Documentation for Medical Necessity

Ensure documentation includes:

  1. Clinical criteria for sepsis (Sepsis-3 or SIRS)
  2. Source of infection
  3. Severity indicators (lactate, organ dysfunction, vasopressor use)
  4. Treatment plan (antibiotics, fluids, vasopressors)
  5. Monitoring plan
  6. Response to therapy

Risk Adjustment & Coding Compliance

Risk Adjustment Best Practices

  1. Annual Capture: Sepsis HCC must be coded at least once per year if chronic effects persist
  2. Documentation Specificity: β€œHistory of sepsis” does not capture HCC - must be current diagnosis
  3. Supporting Evidence: Document labs, cultures, clinical findings
  4. Avoid Downcoding: Use most specific organism code available

Audit Focus Areas

Sepsis coding is heavily audited. Common issues:

  • ❌ Coding sepsis without provider documentation
  • ❌ Using sepsis and bacteremia interchangeably
  • ❌ Coding sepsis based on positive cultures alone (need clinical sepsis)
  • ❌ Incorrect sequencing (postprocedural sepsis)
  • ❌ Missing severe sepsis code (R65.20/R65.21)
  • ❌ Incorrect POA indicator

Compliance Tips

βœ… Provider must document β€œsepsis” - cannot be inferred βœ… Clinical indicators must support diagnosis βœ… Distinguish between sepsis and SIRS βœ… Code to highest specificity when organism known βœ… Follow sequencing guidelines precisely βœ… Accurate POA reporting is mandatory


Quick Reference Card

β”Œβ”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”
β”‚ ICD-10: A41.9 - SEPSIS, UNSPECIFIED ORGANISM                β”‚
β”œβ”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€
β”‚ βœ… HIPAA Valid                                               β”‚
β”‚ βœ… HCC 2 (HIGH value - significant RAF impact)              β”‚
β”‚ ❌ No RVU (diagnosis code)                                   β”‚
β”‚                                                              β”‚
β”‚ CODING REQUIREMENTS:                                         β”‚
β”‚ β€’ Provider must document "sepsis"                           β”‚
β”‚ β€’ Evidence of infection + systemic response                 β”‚
β”‚ β€’ Use specific organism code if known                       β”‚
β”‚                                                              β”‚
β”‚ CRITICAL SEQUENCING:                                         β”‚
β”‚ 1. Underlying condition (if postprocedural)                β”‚
β”‚ 2. A41.9 or specific organism                              β”‚
β”‚ 3. R65.20 (severe sepsis) or R65.21 (shock)               β”‚
β”‚ 4. Organ dysfunction codes                                  β”‚
β”‚                                                              β”‚
β”‚ SEVERE SEPSIS (always add):                                  β”‚
β”‚ β€’ R65.20 - Severe sepsis without shock                      β”‚
β”‚ β€’ R65.21 - Severe sepsis WITH septic shock                  β”‚
β”‚                                                              β”‚
β”‚ NEVER USE:                                                   β”‚
β”‚ β€’ R57.9 for septic shock (use R65.21)                       β”‚
β”‚ β€’ A41.9 if organism is specified                            β”‚
β”‚ β€’ Sepsis codes without provider documentation               β”‚
β”‚                                                              β”‚
β”‚ COMMON CPT PAIRS:                                            β”‚
β”‚ β€’ 99223 - Initial hospital care (high complexity)           β”‚
β”‚ β€’ 99291/99292 - Critical care                               β”‚
β”‚ β€’ 87040 - Blood culture                                     β”‚
β”‚ β€’ 85025 - CBC with differential                             β”‚
β”‚ β€’ 80053 - Comprehensive metabolic panel                     β”‚
β”‚                                                              β”‚
β”‚ DRG IMPACT: DRG 870/871 (Septicemia)                        β”‚
β”‚ QUALITY MEASURE: SEP-1 Bundle                               β”‚
β””β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”€β”˜

Sepsis Bundle Quick Reference (SEP-1)

Within 3 hours (ED) or 1 hour (ICU):

  • Blood cultures before antibiotics
  • Lactate level measured
  • Broad-spectrum antibiotics administered
  • 30 mL/kg crystalloid for hypotension or lactate β‰₯4 mmol/L

Within 6 hours:

  • Vasopressors for hypotension not responsive to fluids (MAP β‰₯65)
  • Reassess volume status and tissue perfusion
  • Remeasure lactate if initial lactate elevated

Clinical Pearls for Coders

πŸ’‘ β€œSepsis” must be documented - You cannot code sepsis based on SIRS criteria or lab values alone

πŸ’‘ Bacteremia β‰  Sepsis - Positive blood culture without systemic inflammatory response is bacteremia (R78.81), not sepsis

πŸ’‘ Severe sepsis requires TWO codes - A41.9 + R65.20 or R65.21 (common miss on audits)

πŸ’‘ Septic shock = R65.21 - Do not use R57.9; R65.21 includes both severe sepsis AND shock

πŸ’‘ Query for organism - If culture is positive but organism not documented in diagnosis, query provider

πŸ’‘ POA matters - Hospital-acquired sepsis significantly impacts quality scores

πŸ’‘ Source matters - Code the source of infection (pneumonia, UTI, etc.) in addition to sepsis

πŸ’‘ Postprocedural sequencing - T81.44- goes FIRST if sepsis is postprocedural

πŸ’‘ HCC documentation - β€œHistory of sepsis” doesn’t count; must be current/acute diagnosis

πŸ’‘ Use specific codes when possible - A41.9 is only for truly unknown organisms


References & Resources

Official Guidelines

  • ICD-10-CM Official Guidelines for Coding and Reporting (Section I.C.1.d - Sepsis)
  • CMS HCC Risk Adjustment Model Documentation
  • Sepsis-3 Definitions (JAMA 2016)

Professional Organizations

  • Society of Critical Care Medicine (SCCM)
  • Infectious Diseases Society of America (IDSA)
  • Surviving Sepsis Campaign

CMS Resources

  • SEP-1 Core Measure specifications
  • Hospital-Acquired Condition (HAC) reporting guidelines

Version Information

Document Created: February 2026
ICD-10-CM Version: FY 2026
CMS-HCC Model: V24/V28
Last Updated: 2026-02-09


Clinical Scenario Examples

Example 1: Sepsis, Organism Unknown

Scenario: 72-year-old admitted with fever, hypotension, elevated WBC. Blood cultures pending. Provider documents β€œsepsis, source unknown.”

Coding:

  • Principal: A41.9 (Sepsis, unspecified organism)

Example 2: Severe Sepsis with Acute Kidney Injury

Scenario: Patient admitted with severe sepsis due to unknown organism. Develops acute kidney injury. No shock.

Coding:

  1. A41.9 (Sepsis, unspecified organism)
  2. R65.20 (Severe sepsis without septic shock)
  3. N17.9 (Acute kidney injury, unspecified)

Example 3: Septic Shock with Multi-Organ Failure

Scenario: Patient with septic shock requiring vasopressors, acute respiratory failure requiring intubation, and AKI.

Coding:

  1. A41.9 (Sepsis, unspecified organism)
  2. R65.21 (Severe sepsis WITH septic shock)
  3. J96.01 (Acute respiratory failure with hypoxia)
  4. N17.9 (Acute kidney injury)

Example 4: Postoperative Sepsis

Scenario: Post-op day 4 following cholecystectomy, patient develops fever and hypotension. Provider documents β€œpostoperative sepsis.”

Coding:

  1. T81.44XA (Sepsis following a procedure, initial encounter)
  2. A41.9 (Sepsis, unspecified organism)
  3. [Code for original procedure reason if still applicable]

Example 5: Pneumonia with Sepsis

Scenario: Patient admitted primarily for treatment of sepsis. Pneumonia identified as the source.

Coding:

  1. A41.9 (Sepsis, unspecified organism) - Principal if admitted FOR sepsis
  2. J18.9 (Pneumonia, unspecified organism) - Source of infection

Notes Section

Facility-Specific Guidelines: [Add your facility’s specific sepsis protocols, documentation requirements, or coding policies here]

Personal Reminders: [Add personal coding notes, common queries at your facility, or frequently missed items]


Tags: ICD10 sepsis infection HCC HCC2 critical-care emergency coding risk-adjustment A41 severe-sepsis septic-shock medterm ICD-10-CM medroot