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Home/Diagnosis/ICD-10 Coding for Infection

ICD-10 Coding for Infection

A41.9
R78.81

Complete ICD-10-CM coding and documentation guide for icd-10 coding for infection includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Infectious disease
Sepsis
Bacteremia
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Key Information: ICD-10 Coding for Infection

Essential facts and insights about ICD-10 Coding for Infection

Use ICD-10 code A41.9 for sepsis, unspecified organism, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Sepsis, unspecified organism

Billable Code
A41.9
Billable

Diagnostic Criteria

  • • Positive blood culture
  • • Elevated lactate levels
  • • SOFA score ≥2

Applicable To

  • • Septicemia NOS

Important Notes

  • • Ensure documentation specifies the presence of sepsis and any associated organ dysfunction.

Bacteremia

Billable Code
R78.81
Billable

Diagnostic Criteria

  • • Positive blood cultures

Applicable To

  • • Presence of bacteria in the blood

Important Notes

  • • Ensure bacteremia is documented as a standalone finding.
Ancillary Codes

Additional codes that may be used with this diagnosis

R78.81

Bacteremia

Use when bacteremia is present without a definitive infection diagnosis.

Frequently Asked Questions

What is the ICD-10 code for sepsis?

The ICD-10 code for unspecified sepsis is A41.9. Use this code when sepsis is diagnosed but the specific organism is not identified.

How do you code bacteremia?

Use ICD-10 code R78.81 for bacteremia when bacteria are present in the blood without a definitive infection diagnosis.

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