Bacterial infection, unspecified

This code signifies a bacterial infection where the specific type of bacteria or the anatomical site of the infection is not documented. It indicates the presence of a bacterial pathogen causing illness without further diagnostic specificity.

Use this code when the medical record clearly states a bacterial infection but lacks details regarding the organism (e.g., "bacterial infection suspected," "infection of bacterial origin"). This is typically a diagnosis of exclusion when more specific bacterial infection codes cannot be assigned due to insufficient information.

• Avoid using this code if a more specific bacterial infection, such as a urinary tract infection or pneumonia, is documented.
• Do not code with R78.81 (Bacteremia, unspecified) as per the Excludes1 note; these conditions are mutually exclusive.
• Always query the provider for greater specificity regarding the type and site of infection before resorting to this unspecified code.