ICD-10 Coding for MSSA Sepsis(A41.01, R65.21)
Complete ICD-10-CM coding and documentation guide for MSSA Sepsis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to MSSA Sepsis
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| A41.01 | Sepsis due to Methicillin-Susceptible Staphylococcus aureus | Use when MSSA is confirmed as the causative organism of sepsis. |
|
| R65.21 | Severe sepsis with septic shock | Use when septic shock is documented alongside sepsis. |
|
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 MSSA sepsis
Essential facts and insights about MSSA Sepsis
Primary ICD-10-CM Codes for mssa sepsis
Decision Criteria
clinical Criteria
- Blood cultures confirm MSSA as the causative organism.
documentation Criteria
- Sepsis due to MSSA is explicitly documented by the physician.
Applicable To
- Sepsis due to MSSA
- MSSA bacteremia with sepsis
Excludes
- Sepsis due to Methicillin-Resistant Staphylococcus aureus (A41.02)
Clinical Validation Requirements
- Blood cultures positive for MSSA
- Explicit documentation of sepsis due to MSSA
Code-Specific Risks
- Incorrectly using A41.9 when MSSA is specified
Coding Notes
- Ensure MSSA is explicitly documented as the cause of sepsis.
R65.21 - Severe sepsis with septic shock
Use when septic shock is documented alongside sepsis.
Applicable To
- Septic shock
Clinical Validation Requirements
- Documentation of septic shock
- Hypotension requiring vasopressors
Coding Notes
Ensure documentation of hypotension and vasopressor use.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Methicillin-Susceptible Staphylococcus aureus as the cause of diseases classified elsewhere
B95.61Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting MSSA Sepsis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code A41.01.
Impact
Clinical: Potential for inappropriate antibiotic therapy., Regulatory: Non-compliance with coding standards., Financial: Loss of reimbursement due to incorrect DRG assignment.
Mitigation Strategy
Always specify MSSA in the diagnosis., Review culture results for organism identification.
Impact
Reimbursement: Incorrect DRG assignment leading to potential underpayment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Always use A41.01 when MSSA is confirmed as the causative organism.
Impact
Failure to document MSSA as the causative organism can lead to audit issues.
Mitigation Strategy
Ensure MSSA is documented in all relevant clinical notes.
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 MSSA Sepsis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for MSSA Sepsis
Use these documentation templates to ensure complete and accurate documentation for MSSA Sepsis. These templates include all required elements for proper coding and billing.
Inpatient Admission for MSSA Sepsis
Specialty: Infectious DiseaseRequired Elements
- Presenting symptoms
- Blood culture results
- Organ dysfunction
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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