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A41.52
ICD-10-CM
Klebsiella pneumoniae sepsis

Find essential information on Klebsiella pneumoniae sepsis diagnosis, including clinical documentation, medical coding (ICD-10 codes A48.3, R65.21), and healthcare guidelines. Learn about identifying, treating, and documenting this severe infection for accurate reporting and improved patient outcomes. This resource covers Klebsiella pneumoniae bacteremia, sepsis due to Klebsiella pneumoniae, and antibiotic resistance considerations for optimal clinical management.

Also known as

Klebsiella sepsis
Gram-negative sepsis due to Klebsiella

Diagnosis Snapshot

Key Facts
  • Definition : Blood infection caused by Klebsiella pneumoniae bacteria.
  • Clinical Signs : Fever, chills, rapid breathing, low blood pressure, altered mental status.
  • Common Settings : Hospital-acquired infections, particularly in ICU, patients with weakened immune systems.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC A41.52 Coding
A40-A41

Other bacterial diseases

Covers sepsis due to Klebsiella pneumoniae.

R65.2

Sepsis of unspecified origin

May be used if Klebsiella is not confirmed.

J15.0

Pneumonia due to Klebsiella pneumoniae

For pneumonia as the source of Klebsiella sepsis.

B96.2

Klebsiella pneumoniae as the cause of diseases classified elsewhere

Use as a secondary code with conditions like pneumonia.

Code-Specific Guidance

Decision Tree for

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

Is the Klebsiella pneumoniae infection systemic?

  • Yes

    Is there organ dysfunction?

  • No

    What is the localized infection site?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Klebsiella pneumoniae sepsis
Escherichia coli sepsis
Pseudomonas aeruginosa sepsis

Documentation Best Practices

Documentation Checklist
  • Klebsiella pneumoniae sepsis diagnosis documentation
  • Sepsis due to Klebsiella pneumoniae ICD-10 coding
  • Document positive Klebsiella pneumoniae culture
  • Specify infection source, e.g., urine, blood
  • Document sepsis criteria (SIRS, qSOFA)
  • Record antibiotic treatment and response

Coding and Audit Risks

Common Risks
  • Sepsis Specificity

    Coding sepsis without documented organ dysfunction due to Klebsiella pneumoniae infection leads to overcoding and potential denials. CDI should query for clarity.

  • Infection Site Coding

    Missing or inaccurate coding of the Klebsiella pneumoniae infection source (e.g., pneumonia, UTI) impacts DRG assignment and reimbursement. Thorough documentation is crucial.

  • SIRS vs Sepsis

    Coding SIRS due to Klebsiella pneumoniae as sepsis without meeting sepsis criteria leads to inaccurate reporting and inflated severity. CDI should ensure appropriate documentation.

Mitigation Tips

Best Practices
  • Document sepsis source & confirm Klebsiella pneumoniae via culture
  • Code accurately using ICD-10 A40.3 for K. pneumoniae sepsis
  • Timely blood cultures, antibiotics crucial for compliant care
  • CDI: Query unclear documentation to specify infection site
  • Monitor antibiotic resistance, update treatment based on results

Clinical Decision Support

Checklist
  • Verify blood culture positive for Klebsiella pneumoniae
  • Confirm SIRS criteria with documented fever, tachycardia, tachypnea
  • Check for organ dysfunction (e.g., elevated creatinine, altered mental status)
  • Review antibiotic susceptibility report for targeted therapy guidance
  • Document sepsis source and severity in accordance with Sepsis-3 guidelines

Reimbursement and Quality Metrics

Impact Summary
  • Klebsiella pneumoniae sepsis reimbursement hinges on accurate coding (ICD-10 A48.3, R65.21) and SOI/ROM documentation for optimal DRG assignment.
  • Sepsis quality metrics like severe sepsis mortality, lactate clearance, and antibiotic timing impact hospital value-based purchasing programs.
  • Timely and effective Klebsiella pneumoniae sepsis treatment reduces length of stay, directly impacting hospital case mix index and resource utilization.
  • Coding validation and clinical documentation improvement programs minimize claim denials and optimize Klebsiella pneumoniae sepsis reimbursement.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code A40.3 Klebsiella sepsis
  • Document blood culture confirmation
  • Query physician for organ dysfunction
  • Specify sepsis source if known
  • Consider R65.21 if severe sepsis

Documentation Templates

Patient presents with suspected Klebsiella pneumoniae sepsis.  Symptoms include fever, chills, tachycardia, tachypnea, and hypotension.  The patient reports recent onset of [Specify source of infection, e.g., pneumonia, urinary tract infection, surgical site infection].  Laboratory findings reveal leukocytosis with a left shift, elevated procalcitonin, and positive blood cultures for Klebsiella pneumoniae.  The patient meets the criteria for sepsis based on the Sepsis-3 definition, demonstrating an acute organ dysfunction as evidenced by [Specify organ dysfunction, e.g., elevated lactate, altered mental status, low urine output].  Differential diagnoses considered include other bacterial infections, viral infections, and non-infectious inflammatory conditions.  Given the positive blood cultures and clinical presentation, a diagnosis of Klebsiella pneumoniae sepsis is made.  Treatment plan includes initiation of broad-spectrum antibiotics, specifically [Specify antibiotic regimen, e.g.,  piperacillin-tazobactam, meropenem], fluid resuscitation with crystalloids, and supportive care including oxygen therapy and vasopressor support as indicated.  Patient will be closely monitored for response to therapy and complications such as septic shock, acute respiratory distress syndrome, and multi-organ failure.  Further investigations will include repeat blood cultures, imaging studies as appropriate (e.g., chest X-ray, CT scan), and source control measures depending on the primary site of infection.  ICD-10 code B96.3 Klebsiella pneumoniae as the cause of diseases classified elsewhere, and code R65.21 Severe sepsis will be utilized for billing and coding purposes.  The patient's prognosis is guarded and depends on the severity of organ dysfunction, response to treatment, and presence of comorbidities.  Continuous reassessment and adjustment of the treatment plan will be performed as needed.
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