A41.02

Billable

Sepsis due to Methicillin resistant Staphylococcus aureus

HCC Category Mapping

V28HCC 2 — Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

0.455

V24HCC 2 — Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

0.455

ESRDHCC 2 — Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

0.000

What This Code Means

A serious bloodstream infection caused by a strain of Staphylococcus aureus bacteria that is resistant to methicillin and related antibiotics. This is a life-threatening condition where the bacteria has spread throughout the body and triggered a severe inflammatory response.

Coding Tips

•Always verify that sepsis is documented in the medical record along with the specific MRSA organism; sepsis requires both the infection and systemic response to be present
•Code A41.02 should be paired with a code for the source of infection (if documented) and any organ dysfunction codes (such as acute kidney injury or respiratory failure) to capture the full clinical picture

Clinical Significance

Sepsis due to methicillin-resistant Staphylococcus aureus (MRSA) is a serious healthcare-associated bloodstream infection requiring vancomycin or alternative anti-MRSA therapy. MRSA sepsis carries higher mortality than MSSA sepsis, increased length of stay, and greater healthcare costs. It is a critical infection control concern requiring contact precautions.

Documentation Requirements

✓Blood cultures positive for Staphylococcus aureus with methicillin resistance confirmed on susceptibility testing
✓Documentation explicitly stating MRSA (not just S. aureus without resistance pattern)
✓Infection source identified (central line, wound, pneumonia, surgical site)
✓Vancomycin trough levels or alternative anti-MRSA antibiotic therapy documentation
✓Infection control measures documented (contact precautions, decolonization protocols)

Commonly Confused Codes

A41.01 (MSSA sepsis) — Critical distinction: MRSA requires vancomycin while MSSA is treated with beta-lactams; susceptibility testing determines the correct code A41.2 (Sepsis due to unspecified staphylococcus) — Use A41.02 when MRSA is confirmed; do not default to unspecified Z16.11 (Resistance to penicillins) — Z16 codes can be used as additional codes but do not replace A41.02 for MRSA sepsis

Code Hierarchy

└A41Other sepsis └A41.0Sepsis due to Staphylococcus aureus └A41.02Sepsis due to Methicillin resistant Staphylococcus aureus

└A41.02Sepsis due to Methicillin resistant Staphylococcus aureus