1. 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

2. 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.

3. 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.

4. 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.

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

6. 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.

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

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

9. 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.

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.

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

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

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

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

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

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

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

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.

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)

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

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

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.