π§¬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: β
Yes (valid for billing/transactions)
HCC Status: β
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 doesnβt specify the pathogen
- The organism doesnβt 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
β οΈ CRITICAL CODING ALERT
Sepsis Coding Rules (ICD-10-CM Guidelines)
ALWAYS follow these sequencing rules:
- Underlying condition first - If sepsis is due to postprocedural infection, code the complication first (T80.2-, T81.4-, etc.)
- Sepsis code second - A41.9 or more specific sepsis code
- Severe sepsis - Add R65.20 (severe sepsis without septic shock) or R65.21 (severe sepsis with septic shock)
- Organ dysfunction - Code any associated acute organ dysfunction
- 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
ββ A30-A49: Other bacterial diseases
ββ A41: Other sepsis
ββ A41.0x: Sepsis due to Staphylococcus aureus
β ββ A41.01: MSSA sepsis
β ββ A41.02: MRSA sepsis
ββ A41.1: Sepsis due to other specified staphylococcus
ββ A41.2: Sepsis due to unspecified staphylococcus
ββ A41.3: Sepsis due to Hemophilus influenzae
ββ A41.4: Sepsis due to anaerobes
ββ A41.5x: Sepsis due to Gram-negative organisms
β ββ A41.50: Gram-negative sepsis, unspecified
β ββ A41.51: E. coli sepsis
β ββ A41.52: Pseudomonas sepsis
β ββ A41.53: Serratia sepsis
β ββ A41.54: Acinetobacter baumannii sepsis
β ββ A41.59: Other Gram-negative sepsis
ββ A41.8x: Other specified sepsis
β ββ A41.81: Enterococcus sepsis
β ββ A41.89: Other specified sepsis
ββ A41.9: Sepsis, UNSPECIFIED organism β¬
οΈ You are here
Related ICD-10-CM Codes
Specific Organism Sepsis Codes (A41.xx)
| Code | Description | Use When |
|---|---|---|
| A41.01 | MSSA sepsis | Methicillin-sensitive staph aureus confirmed |
| A41.02 | MRSA sepsis | Methicillin-resistant staph aureus confirmed |
| A41.2 | Unspecified staph sepsis | Staph species confirmed but sensitivity unknown |
| A41.3 | H. influenzae sepsis | Hemophilus influenzae confirmed |
| A41.4 | Anaerobic sepsis | Anaerobic organism confirmed |
| A41.50 | Gram-negative sepsis, unspecified | Gram-negative organism, species unknown |
| A41.51 | E. coli sepsis | E. coli confirmed |
| A41.52 | Pseudomonas sepsis | Pseudomonas confirmed |
| A41.81 | Enterococcus sepsis | Enterococcus confirmed |
| A41.89 | Other specified sepsis | Other identified organism not elsewhere classified |
Severe Sepsis Codes (ALWAYS use with A41.9)
| Code | Description | When to Add |
|---|---|---|
| R65.20 | Severe sepsis without septic shock | Sepsis + acute organ dysfunction, no shock |
| R65.21 | Severe sepsis WITH septic shock | Sepsis + organ dysfunction + hypotension requiring vasopressors |
Common Organ Dysfunction Codes (use with severe sepsis)
| Code | Description |
|---|---|
| N17.9 | Acute kidney injury, unspecified |
| N17.0 | Acute kidney failure with tubular necrosis |
| J96.00 | Acute respiratory failure, unspecified |
| J96.01 | Acute respiratory failure with hypoxia |
| J96.02 | Acute respiratory failure with hypercapnia |
| K72.00 | Acute and subacute hepatic failure without coma |
| D65 | Disseminated intravascular coagulation |
| I95.9 | Hypotension, unspecified |
| G93.41 | Metabolic encephalopathy |
Postprocedural Sepsis (sequence BEFORE A41.9)
| Code | Description |
|---|---|
| T81.44XA | Sepsis following a procedure, initial encounter |
| T81.44XD | Sepsis following a procedure, subsequent encounter |
| O85 | Puerperal sepsis |
| T80.211A | Bloodstream infection due to central venous catheter, initial |
Related Infection Codes
| Code | Description |
|---|---|
| A40.9 | Streptococcal sepsis, unspecified |
| A02.1 | Salmonella sepsis |
| B37.7 | Candidal sepsis |
| A32.7 | Listerial sepsis |
| R78.81 | Bacteremia (NOT sepsis - different condition) |
HCC (Hierarchical Condition Category) Information
β HCC STATUS: YES - This is a HIGH-VALUE HCC Code
HCC Mapping:
| Model | HCC Category | Description | RAF Impact |
|---|---|---|---|
| CMS-HCC V24 | HCC 2 | Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock | High |
| CMS-HCC V28 | HCC 2 | Sepsis | High |
| HHS-HCC | HCC 2 | Septicemia/Sepsis | High |
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:
- β Must be documented by physician/qualified provider
- β Must be clinically supported (positive cultures, clinical sepsis criteria)
- β Must be treated or monitored during the encounter
- β Must be coded at least once per calendar year for chronic conditions
- β 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:
| DRG | Description | Relative Weight |
|---|---|---|
| 870 | Septicemia or severe sepsis w/o MV >96 hours w MCC | ~1.7-2.0 |
| 871 | Septicemia or severe sepsis w/o MV >96 hours w/o MCC | ~0.9-1.1 |
| 853 | Infectious & 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 Code | Description | Typical Setting |
|---|---|---|
| 99221-99223 | Initial hospital care, per day | Admission for sepsis |
| 99231-99233 | Subsequent hospital care, per day | Daily sepsis management |
| 99238-99239 | Hospital discharge day management | Sepsis recovery discharge |
| 99291 | Critical care, first 30-74 minutes | ICU/septic shock management |
| 99292 | Critical care, each additional 30 minutes | Extended critical care |
| 99223 | Initial hospital care, high complexity | Severe sepsis admission |
| 99233 | Subsequent hospital care, high complexity | Complicated sepsis course |
Emergency Department
| CPT Code | Description |
|---|---|
| 99284 | ED visit, high complexity |
| 99285 | ED visit, high complexity with significant threat to life |
Diagnostic Procedures
| CPT Code | Description | Purpose |
|---|---|---|
| 36415 | Routine venipuncture | Blood cultures |
| 87040 | Blood culture, aerobic | Organism identification |
| 87070 | Culture, bacterial, any source | Source identification |
| 87184 | Susceptibility testing, disk method | Antibiotic sensitivity |
| 87186 | Susceptibility testing, MIC method | Antibiotic sensitivity |
| 87076 | Anaerobic culture | Anaerobic organism identification |
| 85025 | Complete blood count (CBC) with differential | Monitor WBC, bands |
| 80053 | Comprehensive metabolic panel | Organ function assessment |
| 82947 | Glucose (quantitative) | Dysglycemia monitoring |
| 83735 | Magnesium | Electrolyte monitoring |
| 85610 | Prothrombin time (PT) | Coagulation assessment |
| 85730 | Thromboplastin time, partial (PTT) | Coagulation assessment |
| 82803 | Blood gases, any combination | Oxygenation/ventilation status |
| 83520 | Immunoassay, procalcitonin | Sepsis biomarker |
Interventional Procedures
| CPT Code | Description | When Used |
|---|---|---|
| 36556 | Insertion of non-tunneled central catheter (age <5) | Central access for critically ill |
| 36558 | Insertion of non-tunneled central catheter (age β₯5) | Central access |
| 31500 | Intubation, endotracheal, emergency | Respiratory failure |
| 94002 | Ventilation assist and management, initial day | Mechanical ventilation |
| 94003 | Ventilation assist, subsequent days | Ongoing ventilator management |
| 36620 | Arterial catheterization/cannulation | Arterial line for hemodynamic monitoring |
| 93503 | Insertion/placement of Swan-Ganz catheter | Advanced hemodynamic monitoring |
Imaging (Source Identification)
| CPT Code | Description |
|---|---|
| 71046 | Chest X-ray, 2 views |
| 71250 | CT chest without contrast |
| 74150 | CT abdomen without contrast |
| 74176 | CT abdomen and pelvis without contrast |
| 76700 | Ultrasound, abdominal, complete |
| 76775 | Ultrasound, retroperitoneal (kidneys) |
Clinical Considerations
SIRS Criteria (2 or more required for clinical diagnosis)
- β
Temperature >38Β°C (100.4Β°F) or <36Β°C (96.8Β°F)Note: SIRS criteria less emphasized in Sepsis-3 definition - β
Heart rate >90 bpm - β
Respiratory rate >20/min or PaCO2 <32 mmHg - β
WBC >12,000 or <4,000 cells/mmΒ³ 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 β€100 mmHg
- SOFA Score increase β₯2 points (definitive organ dysfunction assessment)
Septic Shock Criteria
Sepsis PLUS:
- Vasopressor requirement to maintain MAP β₯65 mmHg
- Serum lactate >2 mmol/L despite adequate fluid resuscitation
Documentation Requirements for A41.9
Minimum Required Documentation:
- β Physician documentation of βsepsisβ (mandatory)
- β Evidence of infection (clinical or culture-proven)
- β Evidence of systemic response or organ dysfunction
Optimal Documentation Includes:
- Specific term βsepsisβ 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:
- βSIRSβ without mention of infection or sepsis
- βBacteremiaβ without sepsis terminology
- Clinical sepsis without physician documentation
- Organ dysfunction without βsevere sepsisβ 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
| Source | Associated ICD-10 |
|---|---|
| Pneumonia | J15.9, J18.9 |
| Urinary tract | N39.0 |
| Skin/soft tissue | L03.90 |
| Intra-abdominal | K65.9, K57.20 |
| Bloodstream (CLABSI) | T80.211A |
| Bone/joint | M86.9 |
| Unknown | Code 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 βsepsisβ 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 βprincipal diagnosisβ 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 βsevere sepsisβ or βseptic shockβ
- 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
β DO:
- Use providerβs documentation of βsepsisβ - 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
β DONβT:
- Code sepsis without physician documentation of βsepsisβ
- Use A41.9 if organism is specified elsewhere in the record
- Confuse βbacteremiaβ with βsepsisβ (different conditions)
- Use βSIRSβ 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:
- Clinical criteria for sepsis (Sepsis-3 or SIRS)
- Source of infection
- Severity indicators (lactate, organ dysfunction, vasopressor use)
- Treatment plan (antibiotics, fluids, vasopressors)
- Monitoring plan
- Response to therapy
Risk Adjustment & Coding Compliance
Risk Adjustment Best Practices
- Annual Capture: Sepsis HCC must be coded at least once per year if chronic effects persist
- Documentation Specificity: βHistory of sepsisβ does not capture HCC - must be current diagnosis
- Supporting Evidence: Document labs, cultures, clinical findings
- Avoid Downcoding: Use most specific organism code available
Audit Focus Areas
Sepsis coding is heavily audited. Common issues:
- β Coding sepsis without provider documentation
- β Using sepsis and bacteremia interchangeably
- β Coding sepsis based on positive cultures alone (need clinical sepsis)
- β Incorrect sequencing (postprocedural sepsis)
- β Missing severe sepsis code (R65.20/R65.21)
- β Incorrect POA indicator
Compliance Tips
β Provider must document βsepsisβ - cannot be inferred β Clinical indicators must support diagnosis β Distinguish between sepsis and SIRS β Code to highest specificity when organism known β Follow sequencing guidelines precisely β Accurate POA reporting is mandatory
Quick Reference Card
ββββββββββββββββββββββββββββββββββββββββββββββββββββββββββββββββ
β ICD-10: A41.9 - SEPSIS, UNSPECIFIED ORGANISM β
ββββββββββββββββββββββββββββββββββββββββββββββββββββββββββββββββ€
β β
HIPAA Valid β
β β
HCC 2 (HIGH value - significant RAF impact) β
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
ββββββββββββββββββββββββββββββββββββββββββββββββββββββββββββββββ
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
π‘ βSepsisβ must be documented - You cannot code sepsis based on SIRS criteria or lab values alone
π‘ Bacteremia β Sepsis - Positive blood culture without systemic inflammatory response is bacteremia (R78.81), not sepsis
π‘ Severe sepsis requires TWO codes - A41.9 + R65.20 or R65.21 (common miss on audits)
π‘ Septic shock = R65.21 - Do not use R57.9; R65.21 includes both severe sepsis AND shock
π‘ Query for organism - If culture is positive but organism not documented in diagnosis, query provider
π‘ POA matters - Hospital-acquired sepsis significantly impacts quality scores
π‘ Source matters - Code the source of infection (pneumonia, UTI, etc.) in addition to sepsis
π‘ Postprocedural sequencing - T81.44- goes FIRST if sepsis is postprocedural
π‘ HCC documentation - βHistory of sepsisβ doesnβt count; must be current/acute diagnosis
π‘ 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 βsepsis, source unknown.β
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:
- A41.9 (Sepsis, unspecified organism)
- R65.20 (Severe sepsis without septic shock)
- 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:
- A41.9 (Sepsis, unspecified organism)
- R65.21 (Severe sepsis WITH septic shock)
- J96.01 (Acute respiratory failure with hypoxia)
- N17.9 (Acute kidney injury)
Example 4: Postoperative Sepsis
Scenario: Post-op day 4 following cholecystectomy, patient develops fever and hypotension. Provider documents βpostoperative sepsis.β
Coding:
- T81.44XA (Sepsis following a procedure, initial encounter)
- A41.9 (Sepsis, unspecified organism)
- [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:
- A41.9 (Sepsis, unspecified organism) - Principal if admitted FOR sepsis
- J18.9 (Pneumonia, unspecified organism) - Source of infection
Notes Section
Facility-Specific Guidelines: [Add your facilityβs 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
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