A41.81
BillableSepsis due to Enterococcus
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is A41.81 an HCC code?
Yes. A41.81 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 A41.81
For A41.81 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 A41.81 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
A41.81 is the ICD-10-CM diagnosis code for sepsis due to enterococcus. This is a serious bloodstream infection caused by Enterococcus bacteria, a type of germ commonly found in the digestive system that has spread into the blood. This condition requires immediate medical treatment with antibiotics. A41.81 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, A41.81 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 A41.81 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 the documentation clearly states 'sepsis' and 'Enterococcus' to support this specific code; do not use if only a urinary tract infection or localized infection is present. Because A41.81 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 A41.81 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Ensure the documentation clearly states 'sepsis' and 'Enterococcus' to support this specific code; do not use if only a urinary tract infection or localized infection is present
- •Code A41.81 should be paired with a code for the source of infection (such as R65.20 for sepsis without acute organ dysfunction) and any associated organ dysfunction codes if applicable
Clinical Significance
Sepsis due to Enterococcus is a bloodstream infection caused by Enterococcus faecalis or E. faecium, commonly arising from urinary tract, intra-abdominal, or biliary sources. Enterococcal sepsis is of particular concern due to the emergence of vancomycin-resistant Enterococcus (VRE), which severely limits treatment options. It is frequently healthcare-associated.
Documentation Requirements
- ✓Blood cultures positive for Enterococcus species (specify faecalis vs. faecium when available)
- ✓Source of Enterococcal infection (urinary tract, biliary, intra-abdominal, endocarditis)
- ✓Vancomycin susceptibility status — VRE vs. VSE is critical for treatment and infection control
- ✓Sepsis criteria and organ dysfunction documentation
- ✓Healthcare-associated vs. community-acquired infection assessment