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R78.81
ICD-10-CM
Bacteremia

Understanding bacteremia, bloodstream infection, and blood infection diagnosis, treatment, and clinical documentation is crucial for healthcare professionals. This resource provides information on bacteremia symptoms, causes, ICD-10 codes, medical coding guidelines, and best practices for accurate clinical documentation and patient care. Learn about blood culture testing, antibiotic treatment options, and sepsis management related to bacteremia. Explore relevant information for physicians, nurses, and other medical professionals involved in the diagnosis and management of bacteremia and related bloodstream infections.

Also known as

Bloodstream Infection
Blood Infection

Diagnosis Snapshot

Key Facts
  • Definition : Presence of bacteria in the bloodstream.
  • Clinical Signs : Fever, chills, rapid heart rate, low blood pressure, confusion.
  • Common Settings : Hospital-acquired infections, intravenous lines, surgical procedures.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R78.81 Coding
A40-A41

Other bacterial diseases

Covers other bacterial infections, including septicemia.

R78.81

Bacteremia

Specifically identifies a bacterial infection in the bloodstream.

A00-B99

Certain infectious and parasitic diseases

Broad category encompassing various infectious diseases, including bacteremia.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the bacteremia associated with an obstetric cause during pregnancy, childbirth, or the puerperium?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Bacteria in the bloodstream.
Systemic inflammatory response to infection.
Infection originating from a localized site.

Documentation Best Practices

Documentation Checklist
  • Document positive blood culture results.
  • Specify organism identified and sensitivities.
  • Note source of bacteremia if known (e.g., UTI).
  • Document signs/symptoms (e.g., fever, chills).
  • Record treatment plan (e.g., antibiotics).

Coding and Audit Risks

Common Risks
  • Sepsis Miscoding

    Confusing bacteremia with sepsis or severe sepsis can lead to inaccurate coding and DRG assignment.

  • Clinical Validation

    Insufficient documentation to support bacteremia diagnosis may cause coding and billing errors.

  • Unspecified Organism

    Lack of specificity regarding the causative organism impacts coding accuracy and reimbursement.

Mitigation Tips

Best Practices
  • Timely blood cultures, appropriate antibiotics (ICD-10 A49.9, R78.8)
  • Aseptic technique for IV lines, catheters (CPT 77002, 76937)
  • Remove unnecessary catheters promptly (CDI, infection prevention)
  • Hand hygiene, chlorhexidine skin prep (quality measures, compliance)
  • Monitor patient, adjust treatment based on cultures (SNOMED CT 40847001)

Clinical Decision Support

Checklist
  • Verify positive blood culture: organism, source
  • Review patient's signs/symptoms (fever, chills, hypotension)
  • Assess risk factors: central lines, immunosuppression, recent surgery
  • Consider alternative diagnoses: localized infection, drug reaction
  • Document infection source and antibiotic treatment plan

Reimbursement and Quality Metrics

Impact Summary
  • Bacteremia (Bloodstream Infection) reimbursement hinges on accurate coding (ICD-10 A49.9, other B95-B96) and complete clinical documentation.
  • Sepsis and severe sepsis CMS reporting impacts DRG assignment and hospital value-based purchasing program scores.
  • Coding validation and physician query processes improve the quality of bacteremia data for infection control and prevention.
  • Timely blood culture diagnostics and appropriate antibiotic treatment influence bacteremia case severity and length of stay, affecting reimbursement.

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Frequently Asked Questions

Common Questions and Answers

Q: What are the most effective empiric antibiotic treatment strategies for suspected gram-negative bacteremia in critically ill adults, considering current resistance patterns?

A: Empiric antibiotic therapy for suspected gram-negative bacteremia in critically ill adults must cover a broad spectrum of potential pathogens, including resistant organisms like *Pseudomonas aeruginosa* and *Enterobacteriaceae* producing extended-spectrum beta-lactamases (ESBLs) or carbapenemases. Current guidelines, such as those from the Infectious Diseases Society of America (IDSA) and local antibiograms, recommend initial treatment with a combination of a beta-lactam with activity against *Pseudomonas* (e.g., piperacillin-tazobactam, cefepime, meropenem, imipenem-cilastatin) and an aminoglycoside (e.g., gentamicin, tobramycin, amikacin). For patients with risk factors for carbapenem-resistant *Enterobacteriaceae* (CRE), alternative options include ceftazidime-avibactam, meropenem-vaborbactam, or colistin. De-escalation of therapy based on culture results and clinical response is crucial to minimize the emergence of resistance. Consider implementing rapid diagnostic testing, such as PCR or MALDI-TOF, to facilitate prompt identification of the causative pathogen and guide targeted antibiotic therapy. Explore how antimicrobial stewardship programs can optimize antibiotic use in your ICU.

Q: How do I differentiate between true bacteremia and contamination in blood cultures drawn from patients with suspected bloodstream infections?

A: Differentiating true bacteremia from blood culture contamination is a common challenge. Clinicians should consider several factors. True bacteremia is more likely with multiple positive blood cultures, especially if they grow the same organism. The clinical presentation of the patient, including fever, chills, hypotension, and other signs of systemic infection, supports the diagnosis of bacteremia. Common skin contaminants include coagulase-negative staphylococci, *Corynebacterium* species, *Propionibacterium acnes*, and *Bacillus* species. However, these organisms can occasionally cause true infection, especially in immunocompromised patients or those with indwelling medical devices. The time to positivity in blood cultures can also be helpful; rapid growth of pathogens typically suggests true bacteremia. Repeating blood cultures after appropriate skin disinfection helps rule out contamination. Learn more about best practices for blood culture collection and interpretation to improve diagnostic accuracy.

Quick Tips

Practical Coding Tips
  • Code B95.7 for unspecified bacteremia
  • Document infection source if known
  • Query physician for clarity if needed
  • Consider sepsis codes if documented
  • Review blood culture results

Documentation Templates

Patient presents with signs and symptoms suggestive of bacteremia, also known as a bloodstream infection or blood infection.  Clinical manifestations include fever, chills, rigors, tachycardia, hypotension, and altered mental status.  The patient's medical history includes [relevant comorbidities, e.g., diabetes, indwelling catheter, recent surgery].  Physical examination reveals [relevant findings, e.g., warm skin, flushed appearance,  murmur].  Preliminary differential diagnosis includes sepsis, septic shock, and other infectious processes.  Blood cultures have been drawn and sent for laboratory analysis to identify the causative organism and determine antibiotic susceptibility.  Empiric antibiotic therapy has been initiated with [antibiotic name and dosage] pending culture results.  The patient's condition is being closely monitored for signs of clinical deterioration.  Further diagnostic workup may include complete blood count (CBC) with differential, procalcitonin, lactate, and imaging studies as clinically indicated.  Treatment plan includes intravenous fluids, hemodynamic support, and adjustment of antibiotics based on culture results and clinical response.  Patient education provided regarding bacteremia symptoms, treatment, and potential complications.  Coding considerations include ICD-10-CM code for bacteremia (B95.6) and appropriate CPT codes for blood cultures and other diagnostic and therapeutic procedures performed.  Differential diagnosis considerations for billing and medical necessity documentation include sepsis, severe sepsis, and septic shock, to be documented appropriately if suspected or confirmed.