ICD-10 Coding for Bacterial Infection(A49.9, B95.61)
Complete ICD-10-CM coding and documentation guide for Bacterial Infection. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bacterial Infection
A49Primary Range
Bacterial infection of unspecified site
This range includes codes for bacterial infections where the site is not specified, including unspecified bacterial infections.
Bacterial and viral infectious agents
These codes are used as additional codes to identify the infectious agent(s) in diseases classified elsewhere.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| A49.9 | Bacterial infection, unspecified | Use when a bacterial infection is confirmed but the site is not specified. |
|
| B95.61 | Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere | Use as an additional code when MSSA is identified as the causative agent. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for bacterial infection
Essential facts and insights about Bacterial Infection
Primary ICD-10-CM Codes for bacterial infection
Decision Criteria
clinical Criteria
- Presence of bacterial infection without a specified site
Applicable To
- Bacterial infection NOS
Excludes
- Sepsis (A41.-)
Clinical Validation Requirements
- Clinical signs of infection without a specified site
- Positive bacterial cultures without site identification
Code-Specific Risks
- Risk of under-coding if the site is known but not documented
Coding Notes
- Ensure documentation specifies the absence of a known site to use A49.9.
B95.61 - Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere
Use as an additional code when MSSA is identified as the causative agent.
Applicable To
- MSSA infection
Excludes
- Sepsis due to MSSA (A41.01)
Clinical Validation Requirements
- Positive culture for MSSA
- Clinical diagnosis of MSSA-related condition
Coding Notes
Ensure MSSA is documented as the causative agent.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere
B95.61Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bacterial Infection to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code A49.9.
Impact
Clinical: May lead to inappropriate treatment, Regulatory: Non-compliance with coding standards, Financial: Loss of reimbursement opportunities
Mitigation Strategy
Ensure cultures are reviewed and documented, Train staff on importance of specificity
Impact
Reimbursement: Potential underpayment due to lack of specificity, Compliance: Non-compliance with coding guidelines, Data Quality: Decreased accuracy in health records
Mitigation Strategy
Use site-specific codes when the site of infection is documented.
Impact
High risk of audit when unspecified codes are used without justification
Mitigation Strategy
Ensure documentation supports the use of unspecified codes by confirming the absence of a known site.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Bacterial Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bacterial Infection
Use these documentation templates to ensure complete and accurate documentation for Bacterial Infection. These templates include all required elements for proper coding and billing.
Documenting a bacterial infection with unspecified site
Specialty: Internal MedicineRequired Elements
- Patient demographics
- Clinical signs and symptoms
- Laboratory findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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