A54.86
BillableGonococcal sepsis
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is A54.86 an HCC code?
Yes. A54.86 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 A54.86
For A54.86 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 A54.86 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
A54.86 is the ICD-10-CM diagnosis code for gonococcal sepsis. A serious bloodstream infection caused by the bacterium Neisseria gonorrhoeae, which spreads throughout the body and can affect multiple organs. This is a severe complication of untreated gonorrhea that requires immediate medical treatment. A54.86 sits in the ICD-10-CM chapter for certain infectious and parasitic diseases (a00-b99), within the section covering infections with a predominantly sexual mode of transmission (a50-a64).
Under the CMS-HCC V28 risk adjustment model, A54.86 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 A54.86 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.
Verify that sepsis is documented in the medical record with evidence of systemic infection from gonorrhea; do not code sepsis without explicit physician documentation. Because A54.86 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 A54.86 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Verify that sepsis is documented in the medical record with evidence of systemic infection from gonorrhea; do not code sepsis without explicit physician documentation
- •Ensure this code is used only when gonorrhea has progressed to sepsis; for localized gonococcal infections without sepsis, use the appropriate site-specific A54 code instead
Clinical Significance
Gonococcal sepsis represents the most severe form of disseminated gonococcal infection, with Neisseria gonorrhoeae present in the bloodstream causing systemic inflammatory response. This is a life-threatening condition with high mortality that requires ICU-level care and reflects the highest acute illness burden in risk adjustment.
Documentation Requirements
- ✓Positive blood cultures for Neisseria gonorrhoeae
- ✓SIRS criteria met (temperature, heart rate, respiratory rate, WBC count)
- ✓Evidence of organ dysfunction (acute kidney injury, liver failure, coagulopathy, altered mental status)
- ✓Hemodynamic status: hypotension, vasopressor requirements
- ✓Source of primary gonococcal infection documented
Commonly Confused Codes
- •A41.9 (Sepsis, unspecified organism) — When the organism is confirmed as gonococcal, use A54.86 rather than the unspecified sepsis code
- •R65.20 (Severe sepsis without septic shock) — This is a complication code used with sepsis codes; consider whether additional R65.2x coding is appropriate
- •A54.89 (Other gonococcal infections) — For localized gonococcal infections without systemic sepsis criteria