Gram-negative sepsis, unspecified
While ICD-9 had codes whose description included the word “septicemia,” there is no code for septicemia in ICD-10. Physicians should use the term “bacteremia” if there is evidence of bacteria circulating in the blood.
Gram-negative sepsis, unspecified. A41.50 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2020 edition of ICD-10-CM A41.50 became effective on October 1, 2019.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2023 Page 25 of 118 postprocedural infection, followed by code T81.12-, Postprocedural septic shock. Do not assign code R65.21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction.
Infection, infected, infective (opportunistic) B99.9 ICD-10-CM Diagnosis Code B99.9 ICD-10-CM Diagnosis Code A49.9 Enterobacter sakazakii B96.89 Enterobacter sakazakii B96.89 ICD-10-CM Codes Adjacent To B96.89 Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.
R78. 81 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM R78.
ICD-10 code A41. 50 for Gram-negative sepsis, unspecified is a medical classification as listed by WHO under the range - Certain infectious and parasitic diseases .
To identify patients with possible Gram-negative bacteremia in the NPR, we used diagnoses of “septicemia/sepsis due to other Gram-negative organisms” (ICD-10 code A41. 5).
ICD-10 code R78. 81 for Bacteremia is a medical classification as listed by WHO under the range - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified .
Gram negative rod (GNR) infections cause a significant amount of morbidity and mortality amongst hospitalized patients. Patients with poor underlying medical status are most at risk, especially the immunosuppressed, elderly, and patients with malignancies.
Sepsis is defined as a systemic disease caused by microorganisms or their products in the blood. Bacteremia is the presence of viable organisms in the circulation. Gram negative bacteremia in the critically ill patient is synonymous with gram negative sepsis.
Bacteremia is the presence of bacteria in the blood, hence a microbiological finding. Sepsis is a clinical diagnosis needing further specification regarding focus of infection and etiologic pathogen, whereupon clinicians, epidemiologists and microbiologists apply different definitions and terminology.
Bacteremia due to gram-negative bacilli is a significant problem in both hospitalized and community-dwelling patients. These organisms pose serious therapeutic problems because of the increasing incidence of multidrug resistance [1].
ICD-10 code: A49. 9 Bacterial infection, unspecified.
Gram-positive cocci are the most common cause of bloodstream infections in hemodialysis patients, with Staphylococcus aureus and coagulase-negative staphylococci causing most infections.
81, Bacteremia, is a symptom code with an Exclude1 note stating it can't be used with sepsis and that additional documentation related to the cause of the infection, i.e., gram-negative bacteria, salmonella, etc., would be needed for correct code assignment.
If a patient is admitted because of bacteremia, it should be the principal diagnosis even though bacteremia is a symptom code, because it is the condition that occasioned the admission.
For instance, if severe sepsis, pneumonia, and acute renal failure due to dehydration are documented, the code for severe sepsis may not be assigned because the acute renal failure is not stated as due to or associated with sepsis. If the documentation is unclear, query the physician.
You must query the physician when the term “sepsis syndrome” is documented as a final diagnosis. Know when to Query. Sepsis is a complicated condition to code, and it is often necessary to query the physician to code the case correctly.
The discharge diagnoses were influenza with pneumonia bacterial superinfection, positive for pseudomonas, as well as acidosis, asthma exacerbation, hypoxemia, and chronic bronchitis. Sepsis and SIRS were not mentioned on the discharge summary, and are mentioned only sporadically throughout the progress notes.
Post-procedural Sepsis and Sepsis Due to a Device, Implant, or Graft. A systemic infection can occur as a complication of a procedure or due to a device, implant, or graft. This includes systemic infections due to wound infection, infusions, transfusions, therapeutic injections, implanted devices, and transplants.
If the patient has severe sepsis, add R65.2- with the codes for specific organ dysfunctions.
Documentation issues: You can code for sepsis when the physician documents the term “sepsis.”. Documentation should be consistent throughout the chart. Occasionally, during an extended length of stay, sepsis may resolve quickly and the discharging doctor may not include the diagnosis of sepsis on the discharge summary.
term “sepsis” must also be documented to code a systemic infection. This is a major change from ICD-9-CM. If the term “sepsis” is not documented with “SIRS” when it’s due to a localized infection, you must ask for clarification from the physician.