ICD Code A49.9

ICD code A49.9 is a diagnosis for a bacterial infection that is not specified or identified in the medical record.

1. Presence of clinical signs and symptoms consistent with a bacterial infection (e.g., fever, chills, malaise, localized pain, redness, swelling, or purulent discharge)

2. Laboratory or diagnostic evidence suggestive of a bacterial etiology (e.g., elevated white blood cell count, positive inflammatory markers, or suggestive imaging findings)

3. Absence of a clearly identified bacterial pathogen or specific infection site after appropriate evaluation

4. Exclusion of viral, fungal, or other non-bacterial infectious causes

5. Clinical documentation indicating a bacterial infection is present but not further specified or classified

Relevant CPT codes that may be used to treat ICD code A49.9 include:

- 99202–99215 (Evaluation and Management services)

- 87040 (Culture, bacterial; blood, aerobic)

- 87070 (Culture, bacterial; any other source except urine, blood or stool)

- 87186 (Susceptibility studies, antimicrobial)

- 96372 (Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular)

- 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour)

- 36415 (Collection of venous blood by venipuncture)

- 96374 (Therapeutic, prophylactic, or diagnostic injection [IV push])

- 99281–99285 (Emergency Department services)

- 96360–96361 (Intravenous infusion, hydration)

The selection of CPT codes will depend on the specific services rendered in the treatment of ICD code A49.9.

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