Icd 10 Chapter 1 Certain Infectious And Parasitic Diseases

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Human Immunodeficiency Virus (HIV) Infections

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Code only confirmed cases

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Selection and sequencing of HIV codes

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Patient admitted for HIV-related conditionIf a patient is admitted for an HIV-related condition, theprincipal diagnosis should be B20, Humanimmunodeficiency virus [HIV] disease followed byadditional diagnosis codes for all reported HIV-relatedconditions.(b) Patient with HIV disease admitted for unrelatedconditionIf a patient with HIV disease is admitted for an unrelatedcondition (such as a traumatic injury), the code for theunrelated condition (e.g., the nature of injury code)should be the principal diagnosis. Other diagnoseswould be B20 followed by additional diagnosis codesfor all reported HIV-related conditions.(c) Whether the patient is newly diagnosedWhether the patient is newly diagnosed or has hadprevious admissions/encounters for HIV conditions isirrelevant to the sequencing decision.ICD-10-CM Official Guidelines for Coding and ReportingFY 2016Page 18 of 115(d) Asymptomatic human immunodeficiency virusZ21, Asymptomatic human immunodeficiency virus[HIV] infection status, is to be applied when the patientwithout any documentation of symptoms is listed asbeing “HIV positive,” “known HIV,” “HIV testpositive,” or similar terminology. Do not use this codeif the term “AIDS” is used or if the patient is treated forany HIV-related illness or is described as having anycondition(s) resulting from his/her HIV positive status;use B20 in these cases.(e) Patients with inconclusive HIV serologyPatients with inconclusive HIV serology, but nodefinitive diagnosis or manifestations of the illness, maybe assigned code R75, Inconclusive laboratory evidenceof human immunodeficiency virus [HIV].(f) Previously diagnosed HIV-related illnessPatients with any known prior diagnosis of anHIV-related illness should be coded to B20. Once apatient has developed an HIV-related illness, the patientshould always be assigned code B20 on everysubsequent admission/encounter. Patients previouslydiagnosed with any HIV illness (B20) should never beassigned to R75 or Z21, Asymptomatic humanimmunodeficiency virus [HIV] infection status.(g) HIV Infection in Pregnancy, Childbirth and thePuerperiumDuring pregnancy, childbirth or the puerperium, apatient admitted (or presenting for a health careencounter) because of an HIV-related illness shouldreceive a principal diagnosis code of O98.7-, Humanimmunodeficiency [HIV] disease complicatingpregnancy, childbirth and the puerperium, followed byB20 and the code(s) for the HIV-related illness(es).Codes from Chapter 15 always take sequencing priority.Patients with asymptomatic HIV infection statusadmitted (or presenting for a health care encounter)during pregnancy, childbirth, or the puerperium shouldreceive codes of O98.7- and Z21.ICD-10-CM Official Guidelines for Coding and ReportingFY 2016Page 19 of 115(h) Encounters for testing for HIVIf a patient is being seen to determine his/her HIV status,use code Z11.4, Encounter for screening for humanimmunodeficiency virus [HIV]. Use additional codesfor any associated high risk behavior.If a patient with signs or symptoms is being seen forHIV testing, code the signs and symptoms. Anadditional counseling code Z71.7, Humanimmunodeficiency virus [HIV] counseling, may be usedif counseling is provided during the encounter for thetest.When a patient returns to be informed of his/her HIVtest results and the test result is negative, use codeZ71.7, Human immunodeficiency virus [HIV]counseling.If the results are positive, see previous guidelines andassign codes as appropriate.

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Infectious agents as the cause of diseases classified to otherchapters

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Infectious agents as the cause of diseases classified to otherchapters In these instances,it is necessary to use an additional code from Chapter 1 to identify theorganism. A code from category B95, Streptococcus, Staphylococcus,and Enterococcus as the cause of diseases classified to other chapters,B96, Other bacterial agents as the cause of diseases classified to otherchapters, or B97, Viral agents as the cause of diseases classified toother chapters, is to be used as an additional code to identify theorganism. An instructional note will be found at the infection codeadvising that an additional organism code is required.

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Infections resistant to antibiotics

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Infections resistant to antibioticsMany bacterial infections are resistant to current antibiotics. It isnecessary to identify all infections documented as antibiotic resistant.Assign a code from category Z16, Resistance to antimicrobial drugs,following the infection code only if the infection code does not identifydrug resistance.

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Sepsis

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A code from subcategory R65.2, Severe sepsis, shouldnot be assigned unless severe sepsis or an associatedacute organ dysfunction is documented.

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Severe sepsis

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The coding of severe sepsis requires a minimum of 2codes: first a code for the underlying systemic infection,followed by a code from subcategory R65.2, Severesepsis. If the causal organism is not documented, assigncode A41.9, Sepsis, unspecified organism, for theinfection. Additional code(s) for the associated acuteorgan dysfunction are also required.Due to the complex nature of severe sepsis, some casesmay require querying the provider prior to assignment ofthe codes.

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Septic shock

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Septic shock generally refers to circulatory failureassociated with severe sepsis, and therefore, it representsa type of acute organ dysfunction.For cases of septic shock, the code for the systemicinfection should be sequenced first, followed by codeR65.21, Severe sepsis with septic shock or code T81.12,Postprocedural septic shock. Any additional codes forthe other acute organ dysfunctions should also beassigned. As noted in the sequencing instructions in theTabular List, the code for septic shock cannot beassigned as a principal diagnosis.

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Sequencing of severe sepsis

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If severe sepsis is present on admission, and meets the definitionof principal diagnosis, the underlying systemic infection shouldbe assigned as principal diagnosis followed by the appropriatecode from subcategory R65.2 as required by the sequencingrules in the Tabular List. A code from subcategory R65.2 cannever be assigned as a principal diagnosis.When severe sepsis develops during an encounter (it was notpresent on admission), the underlying systemic infection and theappropriate code from subcategory R65.2 should be assigned assecondary diagnoses.Severe sepsis may be present on admission, but the diagnosismay not be confirmed until sometime after admission. If thedocumentation is not clear whether severe sepsis was present onadmission, the provider should be queried.

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Sepsis and severe sepsis with a localized infection

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Sepsis and severe sepsis with a localized infectionIf the reason for admission is both sepsis or severe sepsis and alocalized infection, such as pneumonia or cellulitis, a code(s) forthe underlying systemic infection should be assigned first andthe code for the localized infection should be assigned as asecondary diagnosis. If the patient has severe sepsis, a codefrom subcategory R65.2 should also be assigned as a secondarydiagnosis. If the patient is admitted with a localized infection,such as pneumonia, and sepsis/severe sepsis doesn’t developuntil after admission, the localized infection should be assignedfirst, followed by the appropriate sepsis/severe sepsis codes.

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Methicillin Resistant Staphylococcus aureus (MRSA)Conditions

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Selection and sequencing of MRSA codes

Combination codes for MRSA infectionWhen a patient is diagnosed with an infection that is due tomethicillin resistant Staphylococcus aureus (MRSA), and thatinfection has a combination code that includes the causal organism(e.g., sepsis, pneumonia) assign the appropriate combination codefor the condition (e.g., code A41.02, Sepsis due to Methicillinresistant Staphylococcus aureus or code J15.212, Pneumonia dueto Methicillin resistant Staphylococcus aureus). Do not assigncode B95.62, Methicillin resistant Staphylococcus aureus infectionas the cause of diseases classified elsewhere, as an additionalcode, because the combination code includes the type of infectionand the MRSA organism. Do not assign a code from subcategoryZ16.11, Resistance to penicillins, as an additional diagnosis.

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Other codes for MRSA infection

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Other codes for MRSA infectionWhen there is documentation of a current infection (e.g., woundinfection, stitch abscess, urinary tract infection) due to MRSA, andthat infection does not have a combination code that includes thecausal organism, assign the appropriate code to identify thecondition along with code B95.62, Methicillin resistantStaphylococcus aureus infection as the cause of diseasesclassified elsewhere for the MRSA infection. Do not assign a codefrom subcategory Z16.11, Resistance to penicillins

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Methicillin susceptible Staphylococcus aureus (MSSA)and MRSA colonization

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Methicillin susceptible Staphylococcus aureus (MSSA)and MRSA colonizationThe condition or state of being colonized or carrying MSSA orMRSA is called colonization or carriage, while an individualperson is described as being colonized or being a carrier.Colonization means that MSSA or MSRA is present on or in thebody without necessarily causing illness. A positive MRSAcolonization test might be documented by the provider as “MRSAscreen positive” or “MRSA nasal swab positive”.Assign code Z22.322, Carrier or suspected carrier of Methicillinresistant Staphylococcus aureus, for patients documented as havingMRSA colonization. Assign code Z22.321, Carrier or suspectedcarrier of Methicillin susceptible Staphylococcus aureus, forpatient documented as having MSSA colonization. Colonization isnot necessarily indicative of a disease process or as the cause of aspecific condition the patient may have unless documented as suchby the provider.

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MRSA colonization and infection

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MRSA colonization and infectionIf a patient is documented as having both MRSA colonization andinfection during a hospital admission, code Z22.322, Carrier orsuspected carrier of Methicillin resistant Staphylococcus aureus,and a code for the MRSA infection may both be assigned.