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ICD-10 Coding for Sepsis due to Urinary Tract Infection(A41.51, N39.0)

Complete ICD-10-CM coding and documentation guide for Sepsis due to Urinary Tract Infection. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Sepsis from UTIUrosepsis (deprecated)

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Related ICD-10 Code Ranges

Complete code families applicable to Sepsis due to Urinary Tract Infection

A40-A41Primary Range

Other bacterial sepsis

This range includes codes for sepsis caused by specific bacteria, such as E. coli, which is common in UTIs.

N30-N39

Other diseases of the urinary system

This range includes codes for urinary tract infections, which are often the source of sepsis.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
A41.51Sepsis due to Escherichia coliUse when sepsis is confirmed to be caused by E. coli from a UTI.
  • Positive urine culture for E. coli
  • SIRS criteria met (e.g., fever >38°C, tachycardia)
N39.0Urinary tract infection, site not specifiedUse as a secondary code when UTI is the source of sepsis.
  • Symptoms of UTI such as dysuria, frequency, and urgency
  • Urine culture with significant bacteriuria

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 sepsis due to UTI

Essential facts and insights about Sepsis due to Urinary Tract Infection

Code A41.51 for sepsis due to E. coli and N39.0 for the UTI. Ensure documentation specifies the organism and links the UTI to sepsis.

Primary ICD-10-CM Codes for sepsis due to urinary tract infection

A41.51
Sepsis due to Escherichia coli
Billable Code

Decision Criteria

clinical Criteria

  • Positive urine culture for E. coli and clinical signs of sepsis.

documentation Criteria

  • Documentation must explicitly state 'sepsis due to E. coli UTI'.

Applicable To

  • Sepsis caused by E. coli

Excludes

  • Sepsis due to other organisms

Clinical Validation Requirements

  • Positive urine culture for E. coli
  • SIRS criteria met (e.g., fever >38°C, tachycardia)

Code-Specific Risks

  • Ensure organism is specified to avoid miscoding.

Coding Notes

  • Ensure documentation specifies the organism and links the UTI as the source of sepsis.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Urinary tract infection, site not specified

N39.0
Use as a secondary code to indicate the source of the sepsis.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Sepsis, unspecified organism

A41.9
Use when the organism causing sepsis is not identified.

Acute cystitis without hematuria

N30.00
Use when the infection is localized to the bladder.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Sepsis due to Urinary Tract Infection to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code A41.51.

Impact

Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.

Mitigation Strategy

Always document lab results, Use specific terminology

Impact

Reimbursement: Potential denial of claims due to lack of specificity., Compliance: Non-compliance with ICD-10 coding standards., Data Quality: Inaccurate clinical data and statistics.

Mitigation Strategy

Document 'sepsis due to UTI' with the specific organism.

Impact

Reimbursement: Claims may be denied for incorrect coding., Compliance: Violation of coding guidelines., Data Quality: Redundant data entry.

Mitigation Strategy

Use A41.51 alone without additional organism codes.

Impact

High risk of audit if sepsis is coded without specifying the organism.

Mitigation Strategy

Ensure all sepsis diagnoses include organism identification.

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 Sepsis due to Urinary Tract Infection, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Sepsis due to Urinary Tract Infection

Use these documentation templates to ensure complete and accurate documentation for Sepsis due to Urinary Tract Infection. These templates include all required elements for proper coding and billing.

Sepsis due to E. coli UTI

Specialty: Infectious Disease

Required Elements

  • Organism identification
  • Linkage of UTI to sepsis
  • SIRS criteria documentation

Example Documentation

Patient presents with fever, tachycardia, and positive urine culture for E. coli. Diagnosis: Sepsis due to E. coli UTI.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Urosepsis with fever.
Good Documentation Example
Sepsis due to E. coli UTI confirmed by urine culture (≥10⁵ CFU/mL), fever (38.5°C), leukocytosis (WBC 18,000).
Explanation
The good example specifies the organism and links the UTI to sepsis.

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