Term
| HIV Infection or illness is coded when |
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Definition
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Term
| Does the documentation require evidence of the positive serology or culture to document HIV infection or illness? |
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Definition
| No, the provider's statement of HIV+ status, or the presence of an HIV-related illness is enough |
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Term
| What is the sequencing for HIV codes? |
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Definition
Encounters for HIV-related conditions, B20 is the principle dx.
Encounter for unrelated condition, HIV codes are secondary
For encounters for unrelated condition, the HIV and/or HIV-related conditions are secondary |
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Term
| Which documentation statements are assigned Z21? |
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Definition
Asymptomatic HIV status
HIV+
Known HIV
HIV test positive
similar terminology |
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Term
| Which documentation statements are assigned B20? |
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Definition
AIDs
any HIV-related illness is documented |
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Term
| How do I code in a scenario where the patient has developed an HIV-related illness in the past? |
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Definition
| Once an HIV-related condition has been coded in the patient, Z21 should never again be assigned. Use code B20 |
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Term
| What is the correct code assignment when HIV-related illness occurs during pregnancy, childbirth or the puerperium? |
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Definition
O98.7x for Preg (etc) complicated by HIV disease
followed by B20, followed by the HIV-related illness.
Chapter 15 codes always take precedence |
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Term
| What is the correct code assignment for HIV+ status during pregnancy, childbirth or the puerperium? |
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Definition
O98.7x preg(etc) complicated by HIV+,
followed by Z21 |
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Term
| When a patient is presenting for HIV testing, |
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Definition
| Code Z11.4, screening for HIV, Z71.7 for HIV counseling if provided, and then any high-risk behaviors |
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Term
| When a condition requires identification of the infectious organism causing disease, |
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Definition
| add a code from Chapter 1, for the specified organism or an unspecified code such as B96, other bacterial agents (or B97,for viral) as the cause of disease classified to other chapters |
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Term
| When is a code from z16, resistant to antimicrobial drugs documented? |
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Definition
| as a secondary code following the infection when drug resistance is documented |
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Term
| When documented, assign the appropriate code for an underlying systemic infection for a diagnosis of sepsis. If the type of infection is not specified, what is the code assignment? |
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Definition
| A41.9, sepsis, unspecified organism |
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Term
| When should R65.2x be coded? |
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Definition
When there is documentation of:
"severe sepsis" is documened or there is an associated acute organ dysfunction documented - the organ dysfunction must be documented as linked |
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Term
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Definition
| there is no listing for "urosepsis" in the Alphabetic Index, and Urosepsis is not synonymous with sepsis, so a statement of urosepsis is not assignable to a code. |
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Term
| How do I code when a pt has sepsis and acute organ dysfunction that is related to a condition other than the sepsis? |
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Definition
| Do not code severe sepsis. Code Sepsis with the appropriate coding for the condition causing organ dysfunction along with the organ dysfunction as a manifestation. |
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Term
| How is severe sepsis coded? |
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Definition
2+ codes required:
1st, the underlying systemic infection
2nd, the severe sepsis code from R65.2
If specific organism is not documented, use A41.9 for the infection |
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Term
| How is septic shock coded? |
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Definition
1st, Code the systemic infection
2nd, R65.21, severe sepsis with septic shock, or T81.12, postprocedural septic shock.
then: any additional codes for acute organ dysfunction |
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Term
| Can septic shock be used as the first listed dx? |
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Definition
| No. sequence the code for the systemic infection first |
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Term
| What is the sequencing when severe sepsis is POA? |
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Definition
1st, underlying systemic infection
2nd, code from R65.2
NEVER assign R65.2 as principle dx |
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Term
| Sequencing instructions when sepsis or severe sepsis is present with a localized infection, such as pneumonia or cellulitis, |
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Definition
1st, code for systemic infection
2nd, code for localized infection
then, sepsis code |
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Term
| If a localized infection is POA, and sepsis/severe sepsis develops after admission, code sequence is |
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Definition
1st, code for localized infection
then appropriate sepsis codes |
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Term
| Is there a cause and effect relationship between infections and post-procedural status? |
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Definition
| No, provider must document a causal relationship to use a complication code for infection following a procedure or surgery |
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Term
| When provider documentation supports infection causing sepsis/severe sepsis is d/t a procedure, |
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Definition
1st, code from T81.40-T81.43 for infection following a procedure, or O86.00-O86.03(followed by the T81.4- code)for infection of obstetric surgical wound.
then, code for sepsis/severe sepsis |
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Term
| How do I code an infection following infusion, transfusion, therapeutic injection or immunization? |
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Definition
1st, T88.0-
then, code for specific infection
then, sepsis codes as appropriate if documented with additional codes for acute organ dysfunction |
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Term
| How is post-procedural infection resulting in post-procedural septic shock coded? |
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Definition
1st -T81.4- code for infection following procedure (if obstetric, code O86.0- first, then T81.4-)
2nd - code for specific organism
then T81.12 for postprocedural septic shock
then any acute organ dysfunction
Do not code R65.21 for severe sepsis with septic shock.
T81.12, post-procedural septic shock
then any other acute organ dysfunction |
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Term
| How is a scenario coded when a non-infectious process (trauma or burn) leads to an infection which develops into sepsis/severe sepsis? |
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Definition
Determine whether the non-infections condition or the infection meet the definition of principle dx, coding this one first and the other as secondary.
if severe sepsis:
R65.2, severe sepsis should be assigned with any associated organ dysfunction
Do not code R65.1 SIRS of non-infectious origin in this scenario |
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Term
| In sepsis as a result of a non-infections condition, how many codes from R65, symptoms and signs specifically associated with SIRS can be coded at one time? |
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Definition
| When a non-infectious condition leads to an infection resulting in severe sepsis, assign the appropriate code from subcategory R65.2, Severe sepsis. Do not additionally assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of non- infectious origin. |
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Term
| What statements indicate asymptomatic HIV |
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Definition
HIV infection status
HIV positive
known HIV
HIV test positive |
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Term
| Infectious agents as the cause of diseases classified to other chapters |
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Definition
Certain infections are classified in chapters other than Chapter 1 and no
organism is identified as part of the infection code. In these instances,
it is necessary to use an additional code from Chapter 1 to identify the
organism. B95-B97 |
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Term
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Definition
an infection d/t any organism that triggers SIRS
All codes with sepsis include the concept of SIRS |
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Term
| sepsis that does not result in organ dysfunction should be coded using |
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Definition
| a single code for the type of sepsis |
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Term
| sepsis with acute organ dysfunction that was not documented as r/t another condition, should be coded as |
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Definition
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Term
| How is severe sepsis coded? |
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Definition
severe sepsis requires 2 codes:
code for the underlying systemic infection (if causal organism not identified, use A41.9)
followed by R56.2 for severe sepsis |
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Term
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Definition
| Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction |
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Term
| How is septic shock coded? |
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Definition
For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Postprocedural septic shock.
Any additional codes for the other acute organ dysfunctions should also be assigned. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis |
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Term
| When is R65.2 assigned as a principle dx? |
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Definition
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Term
| If the reason for admission is sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, code.... |
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Definition
a code(s) for
the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis.
If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis.
If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn’t develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes. |
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Term
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Definition
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