ICD-10 Coding for Staph Aureus Bacteremia(A41.01, A41.02, R78.81)
Complete ICD-10-CM coding and documentation guide for Staph Aureus Bacteremia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Staph Aureus Bacteremia
A41.0-A41.9Primary Range
Sepsis due to various organisms
Primary range for coding sepsis due to Staphylococcus aureus, including MSSA and MRSA.
Staphylococcus aureus as the cause of diseases classified elsewhere
Used as a secondary code to identify Staphylococcus aureus as the causative organism.
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 cause of sepsis. |
|
| A41.02 | Sepsis due to Methicillin resistant Staphylococcus aureus | Use when MRSA is confirmed as the cause of sepsis. |
|
| R78.81 | Bacteremia | Use when bacteremia is present without sepsis or a specific infection site. |
|
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 Staph aureus bacteremia
Essential facts and insights about Staph Aureus Bacteremia
Primary ICD-10-CM Codes for staph aureus bacteremia
Decision Criteria
clinical Criteria
- Positive blood culture for MSSA
documentation Criteria
- Explicit mention of MSSA in the medical record
Applicable To
- Sepsis due to MSSA
Excludes
- Sepsis due to MRSA (A41.02)
Clinical Validation Requirements
- Positive blood cultures for MSSA
- Systemic inflammatory response syndrome (SIRS) criteria met
Code-Specific Risks
- Misidentifying MSSA as MRSA
Coding Notes
- Ensure MSSA is documented in the medical record.
A41.02 - Sepsis due to Methicillin resistant Staphylococcus aureus
Use when MRSA is confirmed as the cause of sepsis.
Applicable To
- Sepsis due to MRSA
Excludes
- Sepsis due to MSSA (A41.01)
Clinical Validation Requirements
- Positive blood cultures for MRSA
- Systemic inflammatory response syndrome (SIRS) criteria met
Coding Notes
Ensure MRSA is documented in the medical record.
R78.81 - Bacteremia
Use when bacteremia is present without sepsis or a specific infection site.
Applicable To
- Presence of bacteria in the blood
Excludes
- Sepsis (A41.0-A41.9)
Clinical Validation Requirements
- Positive blood cultures without systemic infection
Coding Notes
Do not use as a principal diagnosis if sepsis is confirmed.
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
B95.61Methicillin resistant Staphylococcus aureus as the cause of diseases classified elsewhere
B95.62Staphylococcus aureus as the cause of diseases classified elsewhere
B95.6XDifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Sepsis due to Methicillin resistant Staphylococcus aureus
A41.02Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.01Sepsis due to unspecified organism
A41.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Staph Aureus Bacteremia 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: Reduced reimbursement due to lack of specificity
Mitigation Strategy
Ensure blood culture results are documented, Specify MSSA or MRSA in all relevant notes
Impact
Reimbursement: Incorrect DRG assignment, leading to reduced reimbursement, Compliance: Non-compliance with ICD-10 coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Sequence A41.01/A41.02 first
Impact
Reimbursement: Potential underpayment due to lack of specificity, Compliance: Failure to meet documentation standards, Data Quality: Inadequate data for quality reporting
Mitigation Strategy
Query: 'Please clarify if Staph aureus is MSSA or MRSA'
Impact
Failure to document MSSA vs MRSA can lead to coding errors
Mitigation Strategy
Implement mandatory documentation checks for organism type
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 Staph Aureus Bacteremia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Staph Aureus Bacteremia
Use these documentation templates to ensure complete and accurate documentation for Staph Aureus Bacteremia. These templates include all required elements for proper coding and billing.
Infectious Disease Progress Note
Specialty: Infectious DiseaseRequired Elements
- Positive blood culture results
- Source of infection
- Antibiotic susceptibility
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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