A41.81

HCC Category Mapping

What This Code Means

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.

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

Commonly Confused Codes