A41.1

HCC Category Mapping

What This Code Means

A serious bloodstream infection caused by a type of staphylococcus bacteria other than the most common strains (like MRSA or aureus). This condition requires immediate medical treatment as the bacteria has spread throughout the body and triggered a severe inflammatory response.

Coding Tips

• •Ensure the documentation specifically identifies the staphylococcus species involved; if it's methicillin-resistant S. aureus (MRSA) or S. aureus, use more specific codes (A41.01 or A41.02) instead
• •Sepsis codes require a secondary code for the source of infection when documented; verify the clinical record identifies which staphylococcus species is responsible to support code selection

Clinical Significance

Sepsis due to other specified staphylococcus captures bloodstream infections caused by coagulase-negative staphylococci (CoNS) such as S. epidermidis, S. lugdunensis, and S. saprophyticus. While often considered contaminants, true CoNS bacteremia is increasingly recognized as a significant cause of prosthetic device infections, central line-associated bloodstream infections, and native valve endocarditis (especially S. lugdunensis).

Documentation Requirements

• ✓Blood cultures identifying a specific staphylococcal species other than S. aureus
• ✓Clinical correlation distinguishing true infection from contamination (multiple positive cultures, clinical signs of sepsis)
• ✓Source identification (central venous catheter, prosthetic device, surgical site)
• ✓Documentation that the provider considers the positive culture clinically significant, not a contaminant
• ✓Susceptibility testing results, as CoNS are frequently methicillin-resistant

Commonly Confused Codes