A41.2

HCC Category Mapping

What This Code Means

A serious bloodstream infection caused by staphylococcus bacteria when the specific type of staph cannot be identified. This is a life-threatening condition where bacteria have entered the bloodstream and triggered a severe inflammatory response throughout the body.

Coding Tips

• •Always attempt to obtain the specific staphylococcus organism type (aureus, epidermidis, etc.) from culture results or clinical documentation, as more specific codes (A41.0, A41.1) are preferred over the unspecified code A41.2
• •Sepsis codes require a secondary code to identify the source of infection when documented; review the medical record for any localized infection site that may have seeded the bloodstream

Clinical Significance

Sepsis due to unspecified staphylococcus is used when staphylococcal bloodstream infection is documented but the specific species (aureus vs. coagulase-negative) or methicillin susceptibility is not identified. This code should be a placeholder pending culture and susceptibility results rather than a final code assignment.

Documentation Requirements

• ✓Blood cultures growing Staphylococcus species without further speciation or susceptibility testing completed
• ✓Clinical sepsis criteria met
• ✓Documentation that staphylococcal species identification is pending or unavailable
• ✓Query provider for species-level identification when results become available
• ✓Clinical context suggesting staphylococcal source

Commonly Confused Codes