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Chapter 1 Guidelines
Certain Indectous and Parasitic Diseases (A00-B99)
| Question | Answer |
|---|---|
| Chapter 1 | A00-B99 |
| Human Immunodeficiency Virus (HIV) Infections | code only confirmed cases |
| Patient admitted for HIV-related condition: | the principal diagnosis should be B20, followed by additional diagnosis codes for all reported HIV-related conditions |
| Patient with HIV disease admitted for unrelated condition: | such as traumatic injury, the code for that unrelated condition should be the principal diagnosis |
| Asymptomatic HIV | Z21 is to be applied when the pt w/o any documentation of symptoms is listed as being "HIV positive", "HIV test positive", or similar. Don't use this code if the term "AIDS" is used. |
| Patients with Inconclusive HIV serology | pt with inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness, may be assigned R75 |
| Previously diagnosed HIV-related illness | should be coded to B20. Never assign R75 or Z21 |
| HIV infection in pregnancy, childbirth and the puerperium | admitted because of an HIV-related illness should receive principal diagnosis of O98.7-, Human immunodeficiency disease complicating preg, followed by B20 and code(s) for the HIV-related illness(es). If asymptomatic HIV: O98.7- followed by Z21 |
| Encounters for testing for HIV | use Z11.4, Encounter for screening for HIV. Use additional codes for any associated high risk behavior. |
| If a patient is being seen for HIV testing... | code the signs and symptoms. An additional couseling code Z1.7 may be used if counseling is provided during the test |
| When a patient returns to be informed of HIV test... | use Z71.7, Human immunodeficiency virus counseling |
| Infections resistant to antibiotics | assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance |
| Sepsis | assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis , unspecified organism |
| Severe Sepsis | requires 2 codes: one for underlying systemic infection followed by a code for subcategory R65.2, Severe sepsis. Additional code(s) for the associated acute organ dysfunction are also required |
| Septic Shock | refers to circulatory failure associated with sever sepsis and represents a type of acute organ dysfunction |
| For cases of Septic Shock, | the code for the systemic infection should be sequenced first, followed by R65.21, Severe sepsis w/septic shock or T81.12, Postprocedural septic shock. Code the organ dysfunction |
| If severe sepsis is POA and meets the definition of principal diagnosis.... | the underlying systemic infection should be assigned as principal diagnosis followed by subcatergory R65.2, Severe sepsis |
| Sepsis and severe sepsis with a localized infection... | if the reason is for both and localized infection, a code(s) for the underlying systemic infection should be assigned 1st and infection 2nd. Also code R65.2 has severe sepsis as 2nd diagnosis |
| If patient is admitted with a localized infection, like pneumonia, and sepsis/severe sepsis doesn't develop until later... | the localized infection should be assigned 1st, then followed by the appropriate sepsis/severe sepsis codes. |
| Sepsis due to a postprocedural infection... | the postprocedural infection code should be coded 1st then the code for the specific infection 2nd. |
Created by:
wallace263
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