A41.4

HCC Category Mapping

What This Code Means

This is a serious bloodstream infection caused by bacteria that grow without oxygen, which can develop from infections in the abdomen, pelvis, or other areas of the body. It represents a life-threatening condition where harmful bacteria have spread throughout the bloodstream.

Coding Tips

• •Ensure the clinical documentation explicitly states 'sepsis' and identifies anaerobic organisms (such as Bacteroides, Clostridium, or Peptostreptococcus) to support this specific code selection
• •Remember to assign an additional code for the source/site of infection if documented (e.g., intra-abdominal infection) and include a code for sepsis-related organ dysfunction (R65.2x) if present

Clinical Significance

Sepsis due to anaerobes represents bloodstream infection by obligate anaerobic bacteria (Bacteroides fragilis, Clostridium species, Fusobacterium, Peptostreptococcus). These infections typically arise from intra-abdominal, pelvic, or oropharyngeal sources and are frequently polymicrobial. Anaerobic sepsis requires specific antibiotic coverage (metronidazole, carbapenems, or piperacillin-tazobactam).

Documentation Requirements

• ✓Blood cultures growing anaerobic organisms (requires anaerobic culture bottles drawn and processed correctly)
• ✓Identification of the specific anaerobic organism when available
• ✓Source of infection documented (intra-abdominal abscess, perforated viscus, aspiration, pelvic infection)
• ✓Sepsis criteria met with organ dysfunction assessment
• ✓Antibiotic regimen covering anaerobic organisms documented

Commonly Confused Codes