1. Infectious and Parasitic Diseases Appendix C – contains information to help with diseases in these chapters Multiple coding often necessary Identify:  Body Site  Severity of the disease  Specific organism  Etiology of infection  Associated signs, symptoms, manifestation

2. Infectious diseases Examples: TB, HIV, Septicemia Late Effects: identifies the underlying cause of a condition currently present in the patient Example: Mental retardation due to old viral encephalitis 319 Unspecified Mental retardation 139.0 Late effects of viral encephalitis

3. HIV Classification Code only confirmed cases of HIV infection/illness; records with statements of “suspected”, “likely”, “possible”, or “questionable” are to be returned to the physician for clarification Codes: 042, V08, and 795.71 are used together to code positive HIV diagnoses.

4. Neoplasms Neoplasm behavior:  Malignant  Primary  Secondary  In Situ  Benign  Uncertain behavior  Unspecified nature

5. Morphology codes (M) Explain the histology and behavior of a neoplasm Four digits with a fifth separated by a forward slash (M8140/3) The fifth digit is the behavior code  /0 benign /1 uncertain/borderline  /2 in situ/ intraepithelial/noninvasive/noninfiltrating  /3 malignant/primary  /6 malignant -2ndary or metastatic  /9 malignant, uncertain if primary or metastatic

6. V Codes Records chemotherapy, radiation therapy, follow-up visits, family history of cancer, history of primary malignancy Designates the malignancy as the principal diagnosis, EXCEPT: when the admission or encounter is SOLELY for administration of chemotherapy, immunotherapy, or radiation therapy When exception: V code is principal diagnosis code, malignancy is additional diagnosis

7. Coding Neoplasms By system By site (anatomical, Primary) Type (previous slide) Asterisk – when it follows the term of location, that code cannot be used, must be more specific Metastatic from – primary is the site the new growth is ‘from’

8. Metabolic/Immunity Disorders Diabetes: with or without meds, types, lead to other illnesses Gout: acute, chronic, with other illnesses Imbalances: Too much or not enough fluid, acid levels, etc.

9. Blood/Organs Anemia: Types, side effects, cause Clotting: Where, cause, complications, due to White blood cells: Diseases, usually need 4 th and 5 th digits Blood forming organs: Tissue damage, organ shut down or transplant

10. Mental Disorders Sections:  Psychoses  Neurotic Disorders, Personality Disorders,  other Nonpsychotic mental disorders  Mental Retardation  Fifth digits occur frequently in mental disorder diagnoses

11. Categories:  Axis I: All psychiatric except personality and mental retardation  Axis II: Personality disorders and mental retardation  Axis III: IDs the presence of general medical conditions  Axis IV: Note clinically relevant psychosocial and environmental problems  Axis V: Indicates the individual’s overall psychological, social and occupational functioning Axes I, II, and III provide diagnostic information

12. Alcohol and Drugs Alcoholism: chronic mental condition coded under Alcohol dependence syndrome – several forms Drug dependence: chronic mental and physical condition coded under drug addiction – several stages Fifth digits for alcohol/drug dependence and abuse: 0 Unspecified 1 Continuous 2 Episodic 3 Remission

13. Therapy for Dependence Detoxification Rehabilitation Coding therapies: Tabular List 94.61 Alcohol rehabilitation (94.64 drug re) 94.62 Alcohol detoxification (94.65 drug de) 94.63 Alcohol rehab and detox (94.66 drug) There are codes for combinations of alcohol and drug dependence