A40.3
BillableSepsis due to Streptococcus pneumoniae
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is A40.3 an HCC code?
Yes. A40.3 maps to Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock under the CMS-HCC V28 risk adjustment model (and Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock under V24).
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for A40.3
For A40.3 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed A40.3 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
A40.3 is the ICD-10-CM diagnosis code for sepsis due to streptococcus pneumoniae. A serious bloodstream infection caused by Streptococcus pneumoniae bacteria that spreads throughout the body and can cause organ failure. This is a life-threatening condition requiring immediate medical treatment with antibiotics. A40.3 sits in the ICD-10-CM chapter for certain infectious and parasitic diseases (a00-b99), within the section covering other bacterial diseases (a30-a49).
Under the CMS-HCC V28 risk adjustment model, A40.3 maps to Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock (HCC 2) with a community, non-dual, aged base RAF weight of 0.455. The V24 model used during the PY2024–PY2025 transition mapped A40.3 the same way and at the same RAF weight. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Ensure documentation clearly states 'sepsis' and identifies Streptococcus pneumoniae as the causative organism; do not code as simple pneumonia or bacteremia. Because A40.3 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for A40.3 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Ensure documentation clearly states 'sepsis' and identifies Streptococcus pneumoniae as the causative organism; do not code as simple pneumonia or bacteremia
- •Code any associated organ dysfunction or septic shock with additional codes (R65.2x for sepsis with organ dysfunction) to capture severity and support medical necessity for intensive care
Clinical Significance
Sepsis due to Streptococcus pneumoniae is a severe systemic infection most commonly arising from pneumococcal pneumonia, meningitis, or spontaneous bacteremia. It carries particularly high mortality in asplenic patients, the elderly, and those with immunodeficiency. Pneumococcal vaccination status is a critical clinical consideration.
Documentation Requirements
- ✓Blood cultures positive for Streptococcus pneumoniae or clinical sepsis with pneumococcal source identified
- ✓Source of pneumococcal infection documented (pneumonia, meningitis, otitis media, sinusitis, spontaneous bacteremia)
- ✓Severity assessment: organ dysfunction, ICU admission, mechanical ventilation
- ✓Functional or anatomic asplenia status if present (significantly increases susceptibility)
- ✓Pneumococcal vaccination history
Commonly Confused Codes
- •J13 (Pneumonia due to Streptococcus pneumoniae) — J13 is the pneumonia; A40.3 is the sepsis — code both when bacteremic pneumococcal pneumonia progresses to sepsis
- •A40.9 (Streptococcal sepsis, unspecified) — Use A40.3 when S. pneumoniae is identified, not the unspecified streptococcal sepsis
- •A40.8 (Other streptococcal sepsis) — A40.3 is the specific code for pneumococcal sepsis; A40.8 is for other non-group A/B/pneumococcal streptococci