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Chapter 1 Guidelines

Certain Indectous and Parasitic Diseases (A00-B99)

QuestionAnswer
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