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B95.3
ICD-10-CM
Enterococcus faecalis

Learn about Enterococcus faecalis (E. faecalis) diagnosis, including clinical documentation, medical coding, and treatment options. Find information on enterococcal infection identification, healthcare protocols, and best practices for managing E faecalis. This resource offers guidance for clinicians and healthcare professionals dealing with Enterococcus faecalis infections.

Also known as

E. faecalis
Enterococcal infection

Diagnosis Snapshot

Key Facts
  • Definition : A common bacterial infection often found in the gut. Can cause infections in other body sites.
  • Clinical Signs : Varies depending on infection site. Can include fever, chills, pain, redness, swelling, or fatigue.
  • Common Settings : Hospitals, healthcare facilities, nursing homes. Can also occur in community settings.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC B95.3 Coding
A41.0

Sepsis due to Enterococcus

Sepsis caused by Enterococcus bacteria.

B95.2

Streptococcus and Enterococcus as the cause of diseases classified elsewhere

Enterococcus infection causing a disease classified in another chapter.

N39.0

Urinary tract infection, site not specified

Urinary tract infection, location unspecified (often caused by Enterococcus).

A00-B99

Certain infectious and parasitic diseases

Broad category including enterococcal infections.

Code-Specific Guidance

Decision Tree for

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

Is the E. faecalis infection localized?

  • Yes

    Specify infection site.

  • No

    Is it bacteremia/septicemia?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Infection caused by Enterococcus faecalis bacteria.
Infection caused by any Enterococcus species.
Infection caused by Vancomycin-Resistant Enterococcus.

Documentation Best Practices

Documentation Checklist
  • Document site of E. faecalis infection (e.g., UTI, wound)
  • Specify source of infection if known (e.g., catheter)
  • Note symptoms and signs (e.g., fever, pain)
  • Document antibiotic susceptibility results
  • Include any relevant comorbidities or risk factors

Coding and Audit Risks

Common Risks
  • Sepsis Miscoding

    Confusing localized enterococcal infection with sepsis can lead to inaccurate coding and inflated reimbursement.

  • Site Specificity

    Lack of documentation specifying the infection site (e.g., UTI, wound) may cause coding errors and rejected claims.

  • Present on Admission

    Proper POA indicator for enterococcal infections is crucial for accurate reporting and affects hospital-acquired infection metrics.

Mitigation Tips

Best Practices
  • Proper hand hygiene reduces E. faecalis transmission. ICD-10: B95.2
  • Prompt catheter removal prevents enterococcal infections. CDI query: Catheter duration?
  • Targeted antibiotic therapy based on culture sensitivity. CPT: 87070, 87186
  • Infection control protocols for isolation precautions. SNOMED CT: 409463002
  • Appropriate CDI, including infection source, for accurate coding. HCC: 188

Clinical Decision Support

Checklist
  • Verify positive culture for E. faecalis (ICD-10 B95.2)
  • Review patient history for risk factors (e.g., UTI, endocarditis)
  • Assess for typical symptoms (e.g., fever, chills, pain)
  • Consider vancomycin resistance; check susceptibility testing

Reimbursement and Quality Metrics

Impact Summary
  • Impact: Accurate coding of E. faecalis (ICD-10 B95.2) impacts MS-DRG assignment and reimbursement.
  • Impact: Correct E. faecalis diagnosis coding affects hospital-acquired infection reporting (HAI).
  • Impact: Proper documentation of Enterococcus faecalis impacts quality metrics related to sepsis management.
  • Impact: Accurate coding and reporting influence antibiotic stewardship program efficacy evaluation.

Streamline Your Medical Coding

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Frequently Asked Questions

Common Questions and Answers

Q: What are the most effective treatment strategies for vancomycin-resistant Enterococcus faecalis (VRE) bacteremia in critically ill patients?

A: Vancomycin-resistant Enterococcus faecalis (VRE) bacteremia in critically ill patients presents a serious therapeutic challenge. Treatment strategies typically involve a combination of antibiotics based on susceptibility testing, often including agents like linezolid, daptomycin, or tigecycline. Source control, such as removal of infected catheters or drainage of abscesses, is crucial. Consider implementing an antimicrobial stewardship program to optimize antibiotic use and minimize resistance development. Explore how combination therapy and newer agents like quinupristin-dalfopristin may play a role in managing complex VRE infections. Consultation with an infectious disease specialist is highly recommended. Learn more about individualized approaches to VRE treatment based on patient-specific factors and local resistance patterns.

Q: How can I differentiate Enterococcus faecalis endocarditis from other causes of infective endocarditis in clinical practice?

A: Differentiating Enterococcus faecalis endocarditis from other causes of infective endocarditis requires a multifaceted approach. While clinical presentation may involve fever, heart murmur, and embolic phenomena, these are not specific to E. faecalis. Blood cultures are essential for diagnosis, and identification of E. faecalis requires specific laboratory testing. Echocardiography plays a vital role in visualizing vegetations and assessing cardiac complications. Distinguishing E. faecalis from other pathogens like Staphylococcus aureus or Streptococcus species is critical for guiding appropriate antibiotic therapy. Explore how the Duke criteria can be used to assist in the diagnosis of infective endocarditis. Consider implementing specific diagnostic algorithms for infective endocarditis which incorporate microbiological and imaging findings. Learn more about the pathogenesis and clinical course of Enterococcus faecalis endocarditis to optimize patient outcomes.

Quick Tips

Practical Coding Tips
  • Code B95.2 for E. faecalis
  • Document infection site
  • Consider sepsis codes if applicable
  • Check for antibiotic resistance documentation
  • Query physician for clarity if needed

Documentation Templates

Patient presents with signs and symptoms suggestive of Enterococcus faecalis infection.  Clinical presentation includes [specific symptoms e.g., fever, chills, urinary urgency, dysuria, abdominal pain, wound infection, bacteremia].  Differential diagnosis considered [list relevant differentials, e.g., UTI caused by other organisms, intra-abdominal abscess, catheter-related bloodstream infection].  Diagnostic workup includes [mention tests performed e.g., urine culture, blood culture, wound culture, imaging studies].  Laboratory results confirm the presence of E. faecalis.  Sensitivity testing reveals susceptibility to [list antibiotics, e.g., ampicillin, vancomycin, gentamicin].  The patient's medical history includes [relevant past medical history, e.g., diabetes, recent surgery, indwelling catheter, immunosuppression].  Assessment indicates [state the diagnosis e.g., urinary tract infection, bacteremia, endocarditis, wound infection] due to Enterococcus faecalis.  Treatment plan includes [specify antibiotics and dosage e.g., IV ampicillin 1g q6h, oral amoxicillin-clavulanate 875mg BID] and supportive care.  Patient education provided regarding medication adherence, potential side effects, and follow-up care.  Plan to monitor patient response to therapy and adjust treatment as needed.  ICD-10 code [relevant ICD-10 code, e.g., B95.2 for Enterococcal infection as the cause of diseases classified elsewhere,  N71.9 for Urinary tract infection, site not specified] considered for medical billing and coding purposes.  Prognosis is [state prognosis based on patient specific factors e.g., good with appropriate antibiotic therapy]. Continued monitoring and reassessment are necessary.