The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 11 Coding Infectious Diseases Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin
Learning Outcomes ·Apply the guidelines for coding diagnoses with HIV. ·Correctly code testing and test results for infectious diseases. ·Distinguish between septicemia and SIRS
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
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
HIV Infections ·Only code this or any other condition when clearly specified in the physician’s notes
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: ·When the patient is asymptomatic, use V08 Asymptomatic human immunodeficiency virus [HIV] infection status
HIV Infections ·Test Positive: ·When the patient has symptoms or manifestations, use 042 Human immunodeficiency virus [HIV] disease
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
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 ·Septicemia: Blood infection, generalized
Blood Infections ·Signs and symptoms include: ·Increased body temperature (fever) ·Change in heart rate ·Change in respiratory rate ·Increased white cell count
Blood Infections ·Pathogen: An identified cause of infection or disease; bacteria or virus
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 ·038.x ·Sepsis (Septicemia + SIRS) ·038.x x ·Severe Sepsis ·038.x x + code for organ failure
Blood Infections ·Septic Shock Codes: ·038.x · or ·+ code for septic shock such as ·+ code for organ dysfunction
Blood Infections ·SIRS without Infection: ·Code the underlying condition · x ·+ code for organ dysfunction, when applicable
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
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 ·Meningitis (viral or bacterial) ·Tetanus (lockjaw) ·Influenza (flu) ·Sexually transmitted diseases (STDs)
Other Infections ·Varicella (chicken pox) ·Rubeola (measles) ·Rubella (German measles) ·Mumps ·Parasitic infections
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