1. For AIDS/HIV
related illness, Use B20.
2. If a
patient is admitted for any HIV related condition - Code HIV (B20) as
primary Dx followed by HIV related conditions.
3. If an
HIV positive patient is admitted for unrelated condition eg, Injury. - Code
unrelated condition as primary Dx followed by B20
4. Asymptomatic
HIV - Use Z21, for a known HIV or HIV positive patient or HIV
test is positive patient without any associated symptoms.
Note: Don’t use Z21 for AIDS or patient treated for HIV related
illness (B20)
5. For
Inconclusive laboratory evidence of HIV - Use R75
6. If a
Pregnant patient admitted with HIV related condition, Use O98.7-
(HIV disease complicating pregnancy, childbirth and the puerperium) as the
primary diagnosis, followed by B20 & code for HIV related condition.
Note: For Asymptomatic patient use Z21 as the secondary code.
7. Encounter
for screening for HIV - Use Z11.4
8. HIV test
results are negative - Use Z71.7 (HIV Counseling).
Sepsis, Severe Sepsis and Septic Shock
1. SEPSIS: If the type of infection or causal organism is not specified,
assign code A41.9 (Sepsis, unspecified organism).
2. SEVERE SEPSIS (If sepsis associated with acute organ dysfunction),
requires a minimum of two codes.
How to code severe sepsis,
- A
code for underlying systemic infection should be coded first, {If the causal
organism is not documented, use A41.9 (Sepsis, Unspecified organism)}
- Followed by a code from subcategory R65.20 (Severe sepsis)
- Additional codes for associated acute organ dysfunction.
Note: If the acute organ dysfunction is not related to the sepsis, don't
code R65.2- (Severe sepsis)
3. SEPTIC SHOCK: Circulatory failure (acute organ dysfunction) associated
with severe sepsis.
How to code
septic shock,
- A
code for underlying systemic infection should be coded first, {If the causal
organism is not documented, use A41.9 (Sepsis, Unspecified organism)}
- Followed by a code R65.21 (Severe sepsis with septic shock)
- Additional codes for associated other acute organ dysfunction.
4. Sepsis due to a post-procedural infection:
T80.2 - Infections following infusion, transfusion, and therapeutic injection,
T81.4 - Infection following a procedure,
T88.0 - Infection following immunization,
O86.0 - Infection of the obstetric surgical wound
Should be coded
first, followed by the code for the specific infection.
If the patient
has severe sepsis the appropriate code from subcategory R65.2- should also be
assigned and the additional code(s) for any acute organ dysfunction.
5. Post-procedural infection and postprocedural septic shock
When a
post-procedural infection has occurred and resulted in severe sepsis and
postprocedural septic shock,
T81.4,
Infection following a procedure, (or)
O86.0,
Infection of obstetrical surgical wound
Should be coded first
Followed by code R65.21 (Severe sepsis with septic shock) &
Code for the systemic infection.
6. Sepsis and severe sepsis associated with a noninfectious
process
Some cases a
noninfectious process like trauma may lead to an infection which can result in
sepsis or severe sepsis.
If the
noninfectious process meets the definition of principal diagnosis, then the
noninfectious conditions should be sequenced first followed by a code for the
resulting infection.
If severe
sepsis is present, a code from category R65.2- should also be assigned along
with any associated acute organ dysfunction codes.
Methicillin-Resistant Staphylococcus aureus (MRSA) Conditions
1. Combination
codes for MRSA infection.
When a patient
is diagnosed with an infection that is due to MRSA and that infection has a
combination code that includes the causal organism, assign the appropriate
combination code for the condition
Eg: A41.02
(Sepsis due to MRSA)
J15.212 (pneumonia due to MRSA)
2. No
combination codes for MRSA infection
When a patient
is diagnosed with an infection that is due to MRSA and that infection doesn’t
have a combination code includes the causal organism, assign the appropriate
code for that condition along with code B95.62 (MRSA infection as the cause of
diseases classified elsewhere) for the MRSA infection.
Methicillin-susceptible
Staphylococcus aureus (MSSA) and MRSA colonization
1. Colonization
means that MSSA or MSRA is present on or in the body without necessarily
causing illness.
Z22.322,
Carrier or suspected carrier of Methicillin-resistant Staphylococcus aureus,
for patients documented as having MRSA colonization.
Z22.321,
Carrier or suspected carrier of Methicillin-susceptible Staphylococcus aureus,
for patient documented as having MSSA colonization.
MRSA colonization and infection
If a patient is
documented as having both MRSA colonization and infection during a hospital
admission,
Assign Z22.322
(Carrier or suspected carrier of Methicillin-resistant Staphylococcus aureus)
and a code for the MRSA infection.