Coding Infectious Diseases The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 11 Coding Infectious Diseases McGraw Hill/Irwin Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved

Learning Outcomes Apply the guidelines for coding diagnoses with HIV. 11 - 2 Learning Outcomes Apply the guidelines for coding diagnoses with HIV. Correctly code testing and test results for infectious diseases. Distinguish between septicemia and SIRS.

11 - 3 Learning Outcomes Identify the differences between severe sepsis and sepsis. Place the codes for severe sepsis in the correct sequence. Determine the correct guidelines for coding tuberculosis.

11 - 4 Introduction Infectious diseases are spread by physical contact, such as a handshake or the exchange of bodily fluids; others can be spread by the touch of a doorknob that has been handled by someone else.

11 - 5 HIV Infections Only code this or any other condition when clearly specified in the physician’s notes.

11 - 6 HIV Infections Testing for HIV: As with other preventive health care encounters or when the patient comes with no signs or symptoms, use a V code.

HIV Infections Test Positive: 11 - 7 HIV Infections Test Positive: When the patient is asymptomatic, use V08 Asymptomatic human immunodeficiency virus [HIV] infection status.

HIV Infections Test Positive: 11 - 8 HIV Infections Test Positive: When the patient has symptoms or manifestations, use 042 Human immunodeficiency virus [HIV] disease.

11 - 9 HIV Infections Once a patient has been reported with code 042, this patient Cannot be reported with V08 ever again, even after the manifestations have been resolved.

11 - 10 HIV Infections Unrelated Conditions: When a patient visits a physician for a concern other than HIV positive status, HIV is almost always reported because it is a systemic disease.

Blood Infections Bacteremia: An abnormal blood culture 11 - 11 Blood Infections Bacteremia: An abnormal blood culture Septicemia: Blood infection, generalized

Blood Infections Signs and symptoms include: 11 - 12 Blood Infections Signs and symptoms include: Increased body temperature (fever) Change in heart rate Change in respiratory rate Increased white cell count

11 - 13 Blood Infections Pathogen: An identified cause of infection or disease; bacteria or virus

11 - 14 Blood Infections Systemic Inflammatory Response Syndrome (SIRS): Signs and symptoms to an unknown pathogen Sepsis: Two or more signs and symptoms; a reaction to a specified pathogen Severe Sepsis: Sepsis + acute organ dysfunction

Blood Infections Septicemia Sepsis (Septicemia + SIRS) Severe Sepsis 11 - 15 Blood Infections Septicemia 038.x Sepsis (Septicemia + SIRS) 038.x + 995.9x Severe Sepsis 038.x + 995.9x + code for organ failure

Blood Infections Septic Shock Codes: 038.x + 995.92 or 995.94 11 - 16 Blood Infections Septic Shock Codes: 038.x + 995.92 or 995.94 + code for septic shock such as 785.52 + code for organ dysfunction

Blood Infections SIRS without Infection: Code the underlying condition 11 - 17 Blood Infections SIRS without Infection: Code the underlying condition + 995.9x + code for organ dysfunction, when applicable

11 - 18 Tuberculosis Tuberculosis does not ONLY affect an individual’s lungs but can infect many different anatomical sites. Correct code will identify the specific anatomical site.

11 - 19 Bacterial Infections Food poisoning is not really a poisoning but an infection: Campylobacter Vibrio Shigella Listeria Salmonella Clostridium perfringens Escherichia coli (E. coli O157)

Other Infections Viral hepatitis, type A Viral hepatitis, type B 11 - 20 Other Infections Viral hepatitis, type A Viral hepatitis, type B Meningitis (viral or bacterial) Tetanus (lockjaw) Influenza (flu) Sexually transmitted diseases (STDs)

Other Infections Varicella (chicken pox) Rubeola (measles) 11 - 21 Other Infections Varicella (chicken pox) Rubeola (measles) Rubella (German measles) Mumps Parasitic infections

11 - 22 Chapter Summary The contagious nature of infectious diseases makes them very serious. The coding of these conditions and their treatment has statistical significance, in addition to the importance of reimbursement.