ICD-10 Code A41.54 | Sepsis due to Acinetobacter baumannii Symptoms, Diagnosis, Billing

Sepsis due to Acinetobacter baumannii is a severe systemic infection caused by the Acinetobacter baumannii bacteria, often associated with healthcare settings. This condition is clinically significant due to its high morbidity and mortality rates, particularly in immunocompromised patients. The ICD-10 Code A41.54 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this critical infection.

What is ICD-10 Code A41.54 for Sepsis due to Acinetobacter baumannii?

ICD-10 Code A41.54 represents sepsis caused by Acinetobacter baumannii, a gram-negative bacterium commonly found in healthcare environments. This code should be used when documenting cases of sepsis that are specifically attributed to this pathogen, allowing for precise clinical documentation and appropriate billing practices. It is essential for capturing the severity of the patient's condition and guiding treatment decisions.

ICD-10 Code A41.54 – Clinical Definition and Explanation of Sepsis due to Acinetobacter baumannii

Sepsis due to Acinetobacter baumannii is a life-threatening condition characterized by a systemic inflammatory response to infection by this opportunistic pathogen. It often arises in patients with compromised immune systems or those undergoing invasive procedures. Prompt recognition and treatment are crucial to prevent severe complications and improve patient outcomes.

Key Clinical Features:

• Fever, chills, and hypotension indicating systemic infection.
• Altered mental status or confusion due to septic encephalopathy.
• Signs of organ dysfunction, such as acute kidney injury or respiratory failure.
• Positive blood cultures identifying Acinetobacter baumannii.

ICD-10 Code A41.54 for Sepsis due to Acinetobacter baumannii – SOAP Notes & Clinical Use

ICD-10 Code A41.54 is utilized in SOAP notes to document the clinical presentation, assessment, and treatment of patients with sepsis due to Acinetobacter baumannii. This code aids in capturing the severity of the condition and supports appropriate clinical decision-making in both acute and chronic care settings.

What Does ICD-10 Code A41.54 for Sepsis due to Acinetobacter baumannii Mean in SOAP Notes?

In SOAP notes, ICD-10 Code A41.54 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of sepsis due to Acinetobacter baumannii. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code A41.54 – Sepsis due to Acinetobacter baumannii

Sepsis due to Acinetobacter baumannii requires urgent medical intervention, often necessitating hospitalization for intensive monitoring and treatment.

Antibiotic Therapy:

• First-line: Carbapenems (e.g., meropenem) for severe infections.
• Alternative: Polymyxins (e.g., colistin) for multidrug-resistant strains.
• Duration: Typically 7-14 days, depending on clinical response.

Supportive Care:

• Fluid resuscitation to maintain hemodynamic stability.
• Vasopressors for persistent hypotension despite fluid therapy.
• Monitoring and management of organ dysfunction.

Infection Control:

• Strict adherence to hand hygiene protocols.
• Isolation precautions for infected patients to prevent transmission.
• Regular environmental cleaning in healthcare settings.

How to Document Symptoms of Sepsis due to Acinetobacter baumannii (ICD-10 A41.54) in SOAP Notes

Subjective:

• Patient reports fever and chills for the past two days.
• Complains of confusion and difficulty breathing.
• History of recent hospitalization and invasive procedures.
• Denies any known allergies.

Objective:

• Temperature: 102°F, Heart rate: 120 bpm.
• Blood pressure: 85/50 mmHg, Respiratory rate: 28 breaths/min.
• Altered mental status observed during examination.
• Positive blood cultures for Acinetobacter baumannii.

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SOAP Note Guidelines for Diagnosing Sepsis due to Acinetobacter baumannii (ICD-10 Code A41.54)

Assessment:

• Diagnosis: Sepsis due to Acinetobacter baumannii, severe.
• ICD-10 Code: A41.54.
• Contributing factors: Recent hospitalization, immunocompromised state.
• Severity: High risk of morbidity and mortality.

Plan:

• Initiate broad-spectrum intravenous antibiotics.
• Administer IV fluids and monitor vital signs closely.
• Consult infectious disease specialist for management.
• Schedule follow-up blood cultures and organ function tests.

Treatment & Plan Section for ICD-10 Code A41.54 – Sepsis due to Acinetobacter baumannii

• Administer appropriate antibiotics based on susceptibility testing.
• Implement fluid resuscitation protocols to stabilize hemodynamics.
• Monitor vital signs and laboratory parameters regularly.
• Educate patient and family about the condition and treatment plan.

Using ICD-10 Code A41.54 for Sepsis due to Acinetobacter baumannii in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings.
• Use the code in acute care settings, including ER and inpatient admissions.
• Align treatment plans with clinical guidelines to support billing.
• Document any complications or comorbidities that may affect care.

Related ICD-10 Codes Often Used with Sepsis due to Acinetobacter baumannii

• A41.51 – Sepsis due to Staphylococcus aureus
• A41.59 – Sepsis due to other specified bacteria
• R65.20 – Severe sepsis without septic shock
• R65.21 – Severe sepsis with septic shock

ICD-10 Code A41.54 in Medical Billing and Insurance for Sepsis due to Acinetobacter baumannii

ICD-10 Code A41.54 is critical for billing in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings to support the diagnosis.
• Use the code in inpatient and outpatient settings as appropriate.
• Ensure compliance with payer guidelines for sepsis coding.
• Include detailed notes on treatment and patient response.

Common CPT Pairings: