CPT (Current Procedural Terminology) codes are five-digit numeric codes used to describe medical, surgical, and diagnostic services. They are maintained by the American Medical Association and used by healthcare providers, insurers, and Medicare for billing and reimbursement.

What is the difference between facility and non-facility rates?

Non-facility (office) rates are what Medicare pays when a service is performed in a physician's office. Facility rates are lower because when a service is performed in a hospital or ambulatory surgery center, the facility bills separately for overhead costs like equipment and supplies.

RVU stands for Relative Value Unit. Medicare uses RVUs to measure the value of physician services based on three components: physician work, practice expense, and malpractice cost. Total RVUs are multiplied by the conversion factor ($33.40 in 2026) to calculate the Medicare payment amount.

Is A41.59 a billable ICD-10-CM code?

Yes. A41.59 (Other Gram-negative sepsis) is a billable/specific ICD-10-CM code and can be reported on a claim when the documentation supports it.

What HCC does A41.59 map to?

A41.59 maps to HCC2 (Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock) in the CMS-HCC V28 risk-adjustment model (Medicare Advantage / Part C) for payment year 2026. Risk-adjustable diagnoses must be documented and resubmitted each year — and survive the CMS-HCC hierarchy and edits — to count toward a member's risk score.

ICD-10-CM · A00–B99BillableHCC2

ICD-10-CM Code A41.59

Other Gram-negative sepsis

Source: CMS ICD-10-CM FY2026Effective October 1, 2025Reviewed by the D3rx Clinical Billing Team

Diagnosis information

Billable

Yes

Valid for claim submission

Chapter

A00–B99

Certain infectious and parasitic diseases

Risk adjustment

HCC

HCC2

Coding or sequencing A41.59? Ask D3 free.Ask

HCC risk adjustment (CMS-HCC V28)

HCC2Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

Model CMS-HCC V28Payment year 2026

In CMS's Hierarchical Condition Category (HCC) model — the risk-adjustment model for Medicare Advantage (Part C) — a documented and submitted A41.59 may contribute to a member's risk score (subject to the CMS-HCC hierarchy and edits), which helps drive the plan's capitated payment for that patient. To count, the diagnosis must be supported to the MEAT standard (Monitored, Evaluated, Assessed, Treated) and reported on an eligible face-to-face encounter at least once each calendar year — risk scores reset annually.

More codes in the A41 category

Other billable ICD-10-CM codes in the same category as A41.59. Coding to the highest specificity the documentation supports is what keeps a claim clean — pick the child code that most precisely matches the diagnosis.

A41.01Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.02Sepsis due to Methicillin resistant Staphylococcus aureus
A41.1Sepsis due to other specified staphylococcus
A41.2Sepsis due to unspecified staphylococcus
A41.3Sepsis due to Hemophilus influenzae
A41.4Sepsis due to anaerobes
A41.50Gram-negative sepsis, unspecified
A41.51Sepsis due to Escherichia coli [E. coli]
A41.52Sepsis due to Pseudomonas
A41.53Sepsis due to Serratia
A41.54Sepsis due to Acinetobacter baumannii
A41.81Sepsis due to Enterococcus

Documentation & coding notes

A41.59 is a billable/specific ICD-10-CM code — it can be reported as a primary or secondary diagnosis when the documentation supports it. Code to the highest level of specificity the record allows.
A41.59 is risk-adjustable: it maps to HCC2 in the CMS-HCC V28 model (payment year 2026), the risk-adjustment model for Medicare Advantage (Part C). For the diagnosis to contribute to a member's risk score it must survive the CMS-HCC hierarchy and edits, be documented to the MEAT standard (Monitored, Evaluated, Assessed, Treated), and be submitted on an eligible face-to-face encounter at least once per calendar year.
Always verify the code against the current ICD-10-CM Official Guidelines and the payer's coverage policy before submitting — coverage, medical necessity edits, and sequencing rules vary by payer.

Related A00–B99 codes

A41.9

Questions about coding A41.59?

Ask D3 — free AI backed by CMS, ICD-10-CM, and major-payer data. Get a cited answer in seconds, no signup.

Ask D3 about A41.59 Browse all ICD-10 codes

Medical coding disclaimer

ICD-10-CM codes and descriptions shown are from the CMS FY2026 official code set and HCC mappings from the CMS-HCC V28 model (payment year 2026), shown for educational reference. Official Guidelines, payer coverage, medical-necessity edits, and sequencing rules vary. Always verify with the current ICD-10-CM Official Guidelines and the payer before submitting claims. D3rx is not responsible for coding or billing outcomes.