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ICD-10 Ch 1 A,B code
Guidelines for infectious and parasitic disease
| Term | Definition |
|---|---|
| Combination coding | one code fully describes the conditions and manifestations |
| Multiple coding | it take more than one code to fully describe the condition |
| Sequencing rule for UTI | UTI code first; bacterial organism next. |
| Coding resistant organisms | Infection first, Z16- next to indicate resistant organism. EXCEPTION: Staph aureus |
| Sepsis | inflammatory response to microbes in tissue, blood, lungs,skin, urinary system. |
| Is this a symptom of sepsis? body temp <97 degrees F | Yes |
| Is this a symptom of sepsis? body temp >100 degrees F | Yes |
| Is this a symptom of sepsis? hypothermia | Yes |
| Is this a symptom of sepsis? fever | Yes |
| Is this a symptom of sepsis? tachycardia | Yes |
| Is this a symptom of sepsis? HR>90 - 100 | Yes |
| Is this a symptom of sepsis? tachypnea (>20 pm) | Yes |
| Is this a symptom of sepsis? PaCO2 <32 mm Hg | Yes |
| Is this a symptom of sepsis? WBC <4K | Yes |
| Is this a symptom of sepsis? WBC > 12k | Yes |
| Severe sepsis | a systemic response to organ dysfunction, hypotension, or collection of fluids in the tissues (hypoperfusion) |
| How does the coder know whether sepsis is severe enough to use R65.2 code? | If it is documented a "severe sepsis" or "SIRS due to organ failure" by the provider. |
| If the provider documents that both SIRS and organ failure are present, but has not documented that the organ failure is related to the SIRS, should the coder consider this to be severe sepsis for the purposes of coding? | No. there must be a documented correlation relationship. |
| How many codes are needed to report severe sepsis? | Three. 1. underlying systemic infection code; 2. subcategory from R65.2 codes; 3. Code(s) for organ dysfunction. |
| What should be coded if there is no documentation of the microorganism causing the sepsis? | Use code for Sepsis, unspecified (A41.9). |
| Is septic shock considered a type of organ dysfunction? | Yes |
| How is septic shock coded? | 1. underlying infection; 2. code R65.21, Severe sepsis with septic shock; 3. Code(s) for organ dysfunction. |
| If septic shock occurs after a procedure, how does coding change? | The Tcode T81.12 (Postprocedural septic shock) replaces the R code R65.21 |
| If severe shock was present upon admission, would a code from subcategory R65.2 ever be used as a principle diagnosis? | No |
| If SIRS develops as a result of a IV infusion, how does coding change? | the postprocedural infection is reported first, followed by the appropriate subcategory under T80s codes, followed by an additional code to identify the microbe/infectious agent. |
| Which is coded as first when the patient presents with both sepsis and a localized infection? | Assign code for underlying systemic infection 1st followed by the code for the localized infection; then add other appropriate codes -such as R65.2 code for severe sepsis and other appropriate codes. |
| If a patient presents with a localized infection and later develops sepsis/severe sepsis, what is coded first? | Localized infection is coded first, then sepsis/severe sepsis codes. |
| If an infection follows a procedure and is documented as related to the procedure, what should be coded first? | Either T81.40 to T81.43 for non-OB or O86.00 to O86.03 for OB should be first coded. followed by the site code (if site is known). Then assign additional codes for sepsis following a procedure; and codes that identify the infectious agent if known. |
| If sepsis occurs and is documented as related to a noninfectious condition (trauma, burns), what is coded first? | The code for the noninfectious condition is first coded, followed by the code for the resulting infection. If severe sepsis is present, next choose an R65.2 code, then codes to identify associated organ dysfunction. |
| Is it necessary to add a SIRS code if the cause of sepsis was a noninfectious condition? | No |
| How many times can a R65 category (Sx/sx specifically assoc w systemic infection and inflammation and infection) code be assigned if the cause of the sepsis was from a noninfectious condition? | Only one code from subcategory R65.2. Do NOT add SIRS code! |
| Coding Zika virus infections. | Code only if confirmed diagnosis is documented as such by provider. |
| Does Zika virus infection have to have documentation of the type of test performed? | No |
| Where are sequelae codes found for viral, and other infections? | Chapter 1, B codes, B90-94 |
| Where in the ICD-10 codebook is HIV coding found? | B20 |
| What is coded in the event of unconfirmed, but suspected HIV? | NOT B20 codes. Just sx/sx until the provider writes HIV as a diagnosis. No test results are needed, simply the provider statement. |
| If a patient is admitted with an HIV-related illness, what is the first code documented? | B20. Additional codes would describe the the HIV-related condition(s). |
| If the visit is for an HIV patient with a non-HIV related condition, what is first coded? Is HIV coded at all in this case? | Reason for encounter is first coded; followed by B20. |
| If a patient has had a positive HIV test, but has no symptoms, how is this documented? | Z21 - Asymptomatic HIV status. |
| If a patient has had an HIV-related condition in the past, but is currently asymptomatic, how should this be coded? | Report B20 at every encounter/visit once (an) HIV-related condition(s) has/have occured. |
| If the patient has been exposed to HIV, hos not tested positive, and has no symptoms, what code should be used? | Z20.6 - exposure to HIV |
| If HIV test results are inconclusive, what code should be reported? | R75. Inconclusive lab evidence of HIV |
| If a patient is in a hospital and the diagnosis is r/o HIV, should this be coded as HIV? | No. Code only HIV that has been documented by the provider. |
| For OB patients with HIV-related condition(s), what should be coded first? | An OB code from Chapter 15, followed by B20, followed by HIV-related condition(s). |
| For OB patients with asymptomatic positive HIV status admitted for care should be coded how? | O98.7 and Z21 |
| Testing for HIV status without sx/sx. Code? | Z11.4. Add codes for any high-risk behaviors. |
| Pt with sx/sx being tested for HIV status. Code? | Code the sx/sx first. Then add additional code for counseling Z71.7, if documented. |
| If encounter is to inform patient of results of HIV test, what is coded? | Z71.7 HIV counseling |
Created by:
ZonaB2
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