Crystal's Coding Hub

Recent Notes

A41.1

Properties2
codeA41.1
statusActive ✅

5 min read

🎗️ICD-10 CM A41.1 — Sepsis due to other specified staphylococcus

Clinical Definition

ICD-10 CM A41.1 represents sepsis caused by a staphylococcus species other than S. aureus, most commonly coagulase-negative staphylococcus (CoNS) such as S. epidermidis, S. saprophyticus, or S. haemolyticus. CoNS sepsis is frequently associated with indwelling central venous catheters, prosthetic devices, and hospital-acquired bloodstream infections, and is a common cause of nosocomial sepsis in immunocompromised and ICU patients.

Clinical documentation should support:

  • Identified or strongly suspected staphylococcus species other than S. aureus (e.g., coagulase-negative staph, S. epidermidis, S. saprophyticus)
  • Provider-documented sepsis (coding is based on provider diagnosis, not strictly Sepsis-3 criteria)
  • Clinical indicators may include SIRS, organ dysfunction, or Sepsis-3 criteria, but are not required if provider clearly documents sepsis
  • Supporting labs such as positive blood cultures (with attention to true infection vs. contaminant, since CoNS is a common skin-flora contaminant), elevated lactate, leukocytosis/leukopenia, or organ failure indicators
  • Source of infection when known (central line, prosthetic joint/valve, dialysis catheter, etc.)

Coding Guidance

Key Coding Rules

  • Assign A41.1 when a specified staphylococcus organism other than S. aureus (e.g., coagulase-negative staph) is documented as the cause of sepsis.
  • Do not assign A41.1 for sepsis due to S. aureus — use A41.01 (MSSA) or A41.02 (MRSA) instead.
  • If the provider documents “staphylococcal sepsis” without further species specification, default to A41.2.
  • Query the provider if a positive blood culture for CoNS is documented but clinical significance (true bacteremia vs. contaminant) is unclear — CoNS is the most common blood culture contaminant.
  • Add R65.20 or R65.21 when severe sepsis or septic shock is present.
  • Add codes for the underlying infection source (e.g., central line-associated bloodstream infection T80.211A, prosthetic device infection).

Sequencing

  • Principal diagnosis: A41.1 when sepsis is the reason for admission.
  • Secondary diagnosis: When sepsis develops after admission (e.g., HAI/CLABSI) or is not the primary reason for encounter.

Includes / Excludes

Includes

  • Sepsis due to coagulase-negative staphylococcus
  • Sepsis due to other specified staphylococcus species (non-aureus)

Excludes

  • Sepsis due to MSSA — A41.01
  • Sepsis due to MRSA — A41.02
  • Sepsis due to unspecified staphylococcus — A41.2
  • Bacteremia NOS — R78.81
  • Neonatal sepsis — P36.-
  • Puerperal sepsis — O85
  • Streptococcal sepsis — A40.-
  • Actinomycotic sepsis — A42.7

Code Tree

A41 Sepsis
├── A41.0 Sepsis due to Staphylococcus aureus
├── A41.1 Sepsis due to other specified staphylococcus
├── A41.2 Sepsis due to unspecified staphylococcus
├── A41.3 Sepsis due to Hemophilus influenzae
├── A41.4 Sepsis due to anaerobes
├── A41.5 Sepsis due to other Gram-negative organisms
├── A41.8 Other specified sepsis
└── A41.9 Sepsis, unspecified organism

MS‑DRG Impact

Like other A41 sepsis codes, A41.1 groups into DRGs 870-872 depending on mechanical ventilation status and presence of MCC/CC.

  • DRG 870 — Septicemia/Severe Sepsis with MV >96 hours
  • DRG 871 — Septicemia/Severe Sepsis without MV >96 hours with MCC
  • DRG 872 — Septicemia/Severe Sepsis without MV >96 hours without MCC

HCC Impact

  • HCC 2 — Sepsis, Severe Sepsis, Septic Shock
  • High-impact RAF condition
  • Requires clear documentation of sepsis criteria and the specific causative organism (not just a positive culture)

Documentation Requirements

To support A41.1, documentation should include:

  • Specific non-aureus staphylococcus organism identified (e.g., coagulase-negative staph, S. epidermidis)
  • Evidence of true clinical infection (not culture contaminant) plus organ dysfunction
  • Source of infection when known (central line, prosthetic device, dialysis access)
  • Clinical indicators: lactate, WBC abnormalities, hypotension, organ failure
  • Treatment: IV antibiotics, line removal, vasopressors, ICU care

Coding Examples

Example 1

Documentation: “Patient with tunneled dialysis catheter presents with sepsis due to coagulase-negative staphylococcus bacteremia.”

Codes:

  • T82.7XXA — Infection/inflammatory reaction due to vascular device (if catheter-related, initial encounter)
  • A41.1 — Sepsis due to other specified staphylococcus
  • Add R65.20 if severe sepsis is documented

Example 2

Documentation: “Sepsis due to Staphylococcus epidermidis bacteremia from infected central line. Severe sepsis with acute kidney injury.”

Codes:

  • A41.1 — Sepsis due to other specified staphylococcus
  • R65.20 — Severe sepsis without septic shock
  • N17.9 — Acute kidney injury

Example 3

Documentation: “Septic shock due to coagulase-negative staphylococcus prosthetic joint infection.”

Codes:

  • T84.54XA — Prosthetic joint infection (principal if causal)
  • A41.1 — Sepsis due to other specified staphylococcus
  • R65.21 — Severe sepsis with septic shock
  • A41.01 — Sepsis due to MSSA
  • A41.02 — Sepsis due to MRSA
  • A41.2 — Sepsis due to unspecified staphylococcus
  • R65.20 — Severe sepsis without shock
  • R65.21 — Severe sepsis with septic shock
  • A41.9 — Sepsis, unspecified organism

Notes for Auditors & Coders

  • Do not confuse A41.1 with A41.02 — A41.1 excludes S. aureus entirely, regardless of methicillin susceptibility.
  • CoNS is the most frequent blood culture contaminant — validate clinical significance (repeat positive cultures, clinical signs of infection) before coding as true sepsis.
  • Ensure sepsis criteria are met; avoid coding based solely on a single positive culture.
  • Query when documentation is unclear regarding organism species or sepsis severity.
  • Validate sequencing rules based on reason for admission (present on admission vs. hospital-acquired/CLABSI).

Sources

CDC/NCHS ICD‑10‑CM Tabular List, A41.1 AAPC ICD-10-CM code reference, A41.1 CMS MS‑DRG Definitions Manual

Graph View

Backlinks