Chapter 14 Infectious and parasitic disease A00-B99

Acute Appendicitis (admitted for appendectomy) Kaposi's sarcoma of skin of chest, due to HIV infection TOTAL LAPAROSCOPIC APPENDECTOMY

K35.80 B20 C46.0

Postmeasles otitis media

B05.3

Acute viral hepatitis (Australian antigen) with hepatitis delta and hepatic coma

B16.0

Acute lymphadenitis due to HIV infection

B20

Candidiasiss, of esophagus, opportunistic, secondary to AIDS

B20 B37.81

Pneumocystis carinii AIDS

B20 B59

Kaposi's sarcoma of oral cavity AIDS EXCISIONAL BIOPSY OF ORAL CAVITY MUCOSA

B20 C46.7 OCB4XZX

Agranulocytosis due to HIV infection

B20 D70.3

Background retinopathy due to AIDS

B20 H35.00

Infectious gammaherpesviral mononucleosis with hepatomegaly

B27.09

Acute respiratory distress due to sin nombre virus

B33.4

Chronic moniliasis of vulva

B37.3

Chronic vulvitis due to monilia with microorganisms resistant to cephalosporin

B37.3 z16.19

Pneumonia due to schistosomiasis

B65.9 J17

Bacteremia and Bacteriuria

Bacteremia—R78.81 -Presence of bacteria in the bloodstream after a trauma or mild infection -Usually transient and ordinarily clears promptly through the body's own immune system Bacteriuria—R82.71 Presence of bacteria in a microscopic examination of the urine Should not be confused with urinary tract infection (N39.0)

AIDS and Other HIV Infections—Code B20

Code B20 is assigned for all types of HIV infections, which are described by a variety of terms, such as: AIDS Acquired immune deficiency syndrome Acquired immunodeficiency syndrome AIDS-related complex (ARC) AIDS-related conditions HIV disease, symptomatic

Drug-Resistant Infections

Distinct ICD-10-CM codes available: Methicillin-susceptible and methicillin-resistant Staphylococcus aureus (MRSA) infection for: Sepsis (A41.01 and A41.02), Infection (A49.01 and A49.02), Infection in diseases classified elsewhere (B95.61 and B95.62), and Pneumonia (J15.211 and J15.212).

Unconfirmed Diagnosis of HIV Infection

Do not assign code B20 when the diagnostic statement indicates that the infection is "?" "suspected," "possible," or "likely." This is an exception to the general guideline that directs assignment of a code for a diagnosis qualified as suspected or possible as if it were established. Confirmation does not require documentation of a positive serology or culture for HIV. The physician's diagnostic statement that the patient is HIV-positive or has an HIV-related illness is sufficient.

Sepsis

Systemic inflammatory response (SIRS) due to infection. Severe cases involve organ dysfunction

Sepsis

Appropriate code for the underlying systemic infection should be assigned. Streptococcal sepsis Category A40 with the third character specifying sepsis due to different streptococci strains Group A (A40.0), Group B (A40.1), Streptococcus pneumoniae (A40.3), Other (A40.8), or Unspecified (A40.9). Sepsis due to Streptococcus group D is assigned to code A41.81, Sepsis due to Enterococcus. Other types of sepsis are classified to other organisms, such as candidal sepsis (B37.7) or disseminated herpes viral disease (B00.7). If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism. Assign additional codes for manifestations when organisms seed infection in another site, such as arteritis, meningitis, and pyelonephritis.

Septicemia

systemic disease associated with pathological presence of microorganisms in the blood

SIRS

systemic inflammatory response syndrome; a systemic response to infection or trauma with such symptoms as fever or tachycardia.

Herpes Zoster of conjunctiva

B02.31

Sepsis and Lab Values

A diagnosis of sepsis can neither be assumed nor ruled out on the basis of laboratory values alone. Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition; however, the provider should be queried. A code for sepsis is assigned only when the physician makes such a diagnosis.

Amebic abscess of brain and lung

A06.6 Z79.2

Pulmonary tuberculosis, infiltrative

A15.0

Acute scarlet fever

A38.9

Sepsis due to methicillin resistant staphylococcus aureus (MRSA)

A41.02

Anaerobic gram negative sepsis

A41.4

Late, latent syphilis

A52.8

Chronic gonococcal cystitis

A54.01

Chronic gonococcal urethritis

A54.01

Encephalitis due to typhus

A75.9 G94

Sepsis Due to Postprocedural Infection

As with all postprocedural complications, code assignment for sepsis due to a postprocedural infection is based on the provider's documentation of the relationship between the infection and the procedure. Assign first the code for the postprocedural infection (such as T80.2-, Infections following infusion, transfusion, and therapeutic injection; T81.4, Infection following a procedure; T88.0-, Infection following immunization; or O86.0, Infection of obstetric surgical wound). Assign second the code for the specific infection. For cases of severe sepsis, assign the appropriate code from subcategory R65.2 and additional code(s) for any acute organ dysfunction.

Drug-Resistant Infections—Category Z16

Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance. Drug-Resistance codes are located in index under Main term: Resistance, Organism(s), to Drug Examples: "multi-drug resistant" or "(specified drug) resistant condition" or similar terminology The code for the infection should be assigned first, followed by the code from category Z16. Assign codes in category Z16 only as additional codes and only when the physician specifically documents an infection that has become drug-resistant to identify the resistance and non-responsiveness of a condition to antimicrobial drugs.

Severe Sepsis and Postprocedural Septic Shock Due to Postprocedural Infection

Assign first the code for the precipitating complication—such as codes T81.43-, Infection following a procedure, or O86.00 to O86.03, Infection of obstetric surgical wound --should be coded first. For infections following infusion, transfusion, therapeutic injection, or immunization, a code from subcategory T80.2, Infections following infusion, transfusion, and therapeutic injection, or code T88.0-, Infection following immunization, should be assigned first, followed by the code to specify the infectious agent. severe sepsis, the appropriate code from subcategory R65.2 should also be assigned along with the code(s) for any acute organ dysfunction. The assignment of additional codes will differ based on whether septic shock is also present: If there is no septic shock, code R65.20, Severe sepsis without septic shock, and a code for the systemic infection are both assigned. If there is septic shock, code T81.12-, Postprocedural septic shock, and a code for the systemic infection are both assigned.

Serologic Testing for HIV Infection

Asymptomatic patient without prior diagnosis of HIV infection or positive-HIV status requests testing to determine his or her HIV status: Assign code Z11.4, Encounter for screening for human immunodeficiency virus [HIV]. Patient shows signs or symptoms of illness or has been diagnosed with a condition related to HIV infection: Code the signs and symptoms or the diagnosis rather than the screening code.

Zika Virus

Code A92.5 is used to report Zika virus disease (Zika). Virus is spread primarily through the bite of infected mosquito. Common symptoms of the virus are fever, rash, joint pain, and conjunctivitis. Zika virus infection during pregnancy can cause a serious birth defect called microcephaly, as well as other severe fetal brain defects.

Positive Tuberculin Test

Care should be taken to differentiate between a diagnosis of tuberculosis and a positive tuberculin skin test without a diagnosis of active tuberculosis. Code R76.11 classifies the following: Nonspecific reaction to tuberculin skin test without active tuberculosis Positive tuberculin skin test without active tuberculosis Positive PPD (skin test) Abnormal result of Mantoux test Tuberculin (skin test) positive Tuberculin (skin test) reactor

Toxic Shock Syndrome—A48.3

Caused by a bacterial infection. Symptoms include high fever of sudden onset, vomiting, watery diarrhea and myalgia, followed by hypotension and sometimes shock. Originally reported almost exclusively in menstruating women using high-absorbency tampons. The organism isolated was Staphylococcus aureus. A similar syndrome has been identified in children and males infected with group A Streptococcus. An additional code from categories B95-B96 is reported to identify the responsible organism.

Hierarchy

Chapter 1 codes take precedence over codes from other chapters for the same condition. Conditions that are not considered to be easily transmissible or communicable are classified in the appropriate body-system chapter, with an additional code from category B95-B97 to indicate the responsible organism.

Septic Shock

Circulatory failure associated with severe sepsis.

Late Effects of Infection or Parasitic Infestation

Code first the residual effect, followed by the appropriate late-effect code, except where the Alphabetic Index instructs otherwise. Do not assign code for the infection itself since it is no longer present. Sequela codes for a residual condition due to previous infection or parasitic infestation: B90 Sequelae of tuberculosis B91 Sequelae of poliomyelitis B92 Sequelae of leprosy B94 Sequelae of other and unspecified infectious and parasitic diseases

Dual classification or multiple coding is also sometimes the result when coding Infectious and parasitic diseases.

For Ex, Myocarditis with typhus fever is coded A75.9 and I41. There is a note under Myocarditis to code first underlying disease, such as Typhus (A75.0-A75.9) Some bacterial organisms are resistant to certain antibiotics. when a resistant bacteria is identified and it the resistance is not noted in the infection code, you must use an additional code (a Z code) for the resistant status. The Z code can be found under the main term Resistance, Resistant, and is coded after the infection code.

Severe Sepsis

Generally refers to sepsis with associated acute or multiple organ dysfunction. Subcategory R65.2 (Severe sepsis) is further subdivided: With septic shock (R65.21) Without septic shock (R65.20) Septic shock generally refers to circulatory failure associated with severe sepsis and therefore represents a type of acute organ dysfunction. The physician must specifically record "septic shock" in the diagnostic statement in order to code it as such. Septic shock indicates the presence of severe sepsis. Code R65.21, Severe sepsis with septic shock, must be assigned, even if the term "severe sepsis" is not documented. A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented. When a patient has sepsis and an acute organ dysfunction, but the documentation indicates that the acute organ dysfunction is related to a medical condition other than sepsis, codes from subcategory R65.2 should not be used. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, the provider should be queried. Due to the complex nature of severe sepsis, some cases may require querying the provider prior to code assignment.

Gram-Negative Bacterial Infection

Gram-negative bacteria are a specific group of organisms with particular staining characteristics. They are clinically similar and are thought of as a group even when the specific organism cannot be determined. Occasionally, several gram-negative organisms may be seen, but no single organism is identified as the causative agent, resulting in a diagnosis of gram-negative infection. Gram-negative infections are ordinarily more severe and require more intensive care than gram-positive infections. A code is never assigned solely on the basis of gram-stain results. The assignment is based on the physician's clinical evaluation of the condition. When the infectious organism has been identified, a specific code is often provided. Certain infections are classified in chapters other than chapter 1, and no organism is identified as part of the infection code—for example, urinary tract infection (N39.0). In these instances, an additional code from categories B95-B97 is assigned to indicate the responsible infectious agent. An instructional note will be found at the infection code advising coders to assign an additional code to identify the organism.

Methicillin-resistant Staphylococcus aureus (MRSA) Infection

If a combination code that includes the causal organism (e.g., sepsis, pneumonia) exists: Assign the combination code for the condition (e.g., code A41.02, Sepsis due to Methicillin resistant Staphylococcus aureus). Do not assign code B95.62, Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere, as an additional code, because the combination code includes the type of infection and the MRSA organism. If no combination code that includes the causal organism exists: Assign the appropriate code to identify the condition, along with code B95.62, Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere, for the MRSA infection.

Sepsis and Severe Sepsis with Localized Infection

If reason for admission is both a localized infection and sepsis or severe sepsis: Assign systemic infection first. Secondary diagnosis: localized infection. Assign code from subcategory R65.2, Severe sepsis, if applicable. If reason for admission is localized infection, and sepsis/SIRS does not develop until after admission: Localized infection, such as pneumonia, may be principal diagnosis. Secondary diagnosis: codes for sepsis/severe sepsis.

Sepsis and Severe Sepsis Associated with Non-Infectious Process (cont.)

If the infection meets the definition of principal diagnosis: Code the infection first; Then add the non-infectious condition. When both the associated non-infectious condition and the infection meet the definition of principal diagnosis: Either may be assigned as the principal diagnosis. Only one code from category R65, Symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. When a noninfectious 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.

Combination codes are frequently used when coding Infectious and parasitic diseases.

If the organism is identified in the code, only one code is needed. Ex, Rotaviral Gastroenteritis is coded A08.0 This code describes the gastroenteritis and the viral organisms so there is no need for additional codes.

Sepsis and Severe Sepsis Associated with Non-Infectious Process

In some cases, a non-infectious process (condition), such as trauma, may lead to an infection which can result in sepsis or severe sepsis. If sepsis or severe sepsis is documented as associated with a non-infectious condition (e.g., burn, serious injury), and this condition meets the definition of principal diagnosis: Code non-infectious condition first; Followed by the code for the resulting infection. If severe sepsis is present, a code from subcategory R65.2 should also be assigned with any associated organ dysfunction(s) codes. It is not necessary to assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of non-infectious origin, for these cases.

Important factor to remember: primary axis for coding infectious parasitic disease is the Infectious organism.

Infectious organism is the bacteria, virus, parasites, fungus, etc. When a condition is identified as being due to a specific organism, the code that best identifies the organism takes precedence over the condition. example: acute salmonella Osteomyelitis of the finger. Main term- Osteomyelitis Subterm - Salmonella A02.24 look up this condition in the index by infection, salmonella, localized, osteomyelitis.

Colonization vs. Infection

It is important to distinguish colonization from infection. Colonization or carrier-infectious organism (e.g., MRSA) is present on or in the body without necessarily causing illness: Not necessarily indicative of a disease process or as the cause of a specific condition unless documented as such by the provider. A positive colonization test might be documented as "MRSA screen positive" or "MRSA nasal swab positive." See code Z22 for carrier or suspected carrier of infectious diseases Staphylococcus (Z22.321 or Z22.322) Group B streptococcus (Z22.330) If a patient is documented as having both MRSA colonization and MRSA infection during a hospital admission, code Z22.322, Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus, and a code for the MRSA infection may both be assigned.

Adenoviral pneumonia

J12.0

Acute empyema due to group B streptococcal infection

J86.9 B95.1

Serologic Testing for HIV Infection (cont.)

Patient makes a return visit to learn the result of the serology test: Assign code Z71.7, Human immunodeficiency virus [HIV] counseling, as the reason for the encounter when the test result is either positive or negative, or inconclusive (R75). Code Z71.7 can be assigned as an additional code when counseling is provided for patients who test HIV positive. Patient is known to be in a high-risk group for HIV infection: Code Z72.89, Other problems related to lifestyle, can be assigned as an additional code. Test result is positive, but the patient displays no symptoms and has no related complications and no established diagnosis of HIV infection: Assign code Z21, Asymptomatic human immunodeficiency (HIV) infection status. Do not assign code Z21 when the term AIDS is used, when the patient is under treatment for an HIV-related illness, or when the patient is described as having any active HIV-related condition: Assign code B20 Patient has had contact with, or been exposed to, the HIV virus but shows no signs or symptoms of illness and has not been diagnosed with a condition related to HIV: Assign code Z20.6, Contact with and (suspected) exposure to human immunodeficiency virus [HIV]. Newborns with HIV-positive mothers often test positive on ELISA and/or western blot HIV tests: This finding usually indicates the antibody status of the mother rather than the status of the newborn. Such inconclusive test results are also coded R75.

Bacteremia

Presence of bacteria in the bloodstream after a trauma or an infection

Inconclusive HIV test

R75

Urosepsis

Refers to pyuria or bacteria in the urine, not the blood. -Sometimes stated as the diagnosis even though the condition has progressed from a localized urinary tract infection and has become a generalized sepsis. -Nonspecific term and should not be considered synonymous with sepsis. -Urosepsis has no default code in the Alphabetic Index. When this term is documented, the coder should consult the provider for clarification.

Coding and Sequencing of Severe Sepsis

Requires a minimum of two codes: Underlying infection (e.g., A40.-, A41.-, or B37.7) first. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Code from subcategory R65.2, Severe sepsis. An additional code(s) should also be assigned for the associated acute organ dysfunction. Severe sepsis may be present on admission, but the diagnosis may not be confirmed until sometime after admission. When the documentation is not clear as to whether severe sepsis was present on admission, the provider must be queried for clarification.

Nosocomial Infections

Secondary infections that are contracted as a result of medical treatment or develop during hospitalization. A.K.A. "hospital-acquired infections." Code Y95 -Nosocomial condition (used as an additional External cause of morbidity code to identify these infections)

Systemic Inflammatory Response Syndrome (SIRS)

Systemic response to infection, trauma/burns, or other insult (such as cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis. SIRS of noninfectious origin is coded to subcategory R65.1 depending on whether acute organ dysfunction is present (R65.11) or not (R65.10). ICD-10-CM does not provide a separate code or index entry for SIRS due to an infectious process, and the condition does not automatically equate to sepsis.

Enterococcal septic shock due to acute postoperative peritonitis (surgery same admission)

T81.43xa T81.12xa A41.81 K65.0

Infectious and Parasitic Diseases

The primary axis for this chapter of ICD-10-CM is the organism responsible for the condition. Infectious and parasitic conditions are classified in one of several ways: A single code from chapter 1 to indicate the organism Combination codes to identify both the condition and the organism Dual classification is also used extensively for chapter 1.

West Nile Virus Fever—Subcategory A92.3

Virus is transmitted by mosquito bite. Most healthy people infected by the virus have few symptoms or have mild illness with fever, headache, and body aches. In elderly patients or patients with a weakened immune system, the virus may cause encephalitis, meningitis, or permanent neurologic damage and may be life-threatening. Codes: West Nile virus infection unspecified (A92.30), With encephalitis (A92.31), With other neurologic manifestation (A92.32), and With other complications (A92.39).

Sequencing of HIV-Related Diagnoses

When a patient is admitted for treatment of an HIV infection or any related complications: Principal diagnosis: B20, Human Immunodeficiency Virus (HIV) disease. Assign additional codes for the HIV-related conditions. When a patient with an HIV infection is admitted for treatment of an entirely unrelated condition, such as an injury: Principal diagnosis: The unrelated condition. Additional codes: B20 and codes for any associated conditions. When an obstetric patient is identified as having any HIV infection: Principal diagnosis: a code from subcategory O98.7, Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium. Additional codes: B20 is assigned as an additional code. When an obstetric patient tests positive for HIV but has no symptoms and no history of an HIV infection: Assign code Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, rather than code B20.

Organism vs. Site or Other Subterm

When the main term for the condition has been located, a subterm for the organism always takes precedence over a more general subterm (such as acute or chronic) when both subterms occur at the same indentation level in the Alphabetic Index. When the organism is specified but is not indexed under the main term for the condition, refer to the main term Infection or to the main term for the organism.

Positive HIV test in patient who is asymptomatic, presents no related symptoms, and has no history of HIV infection

Z21

Tuberculosis Categories A15-A19

bacterial disease caused by Mycobacterium tuberculosis and Mycobacterium bovis. -People with weakened immune systems are at increased risk for contracting TB. -spread through the air when a person with untreated pulmonary TB coughs or sneezes. Classified based on the general site or type of tuberculosis: A15 Respiratory tuberculosis A17 Tuberculosis of nervous system A18 Tuberculosis of other organs A19 Miliary tuberculosis Categories A15, A17, and A18 are subdivided further to specify the site. Tuberculosis usually affects the lungs (code A15.0), although other parts of the body can also be affected: Intrathoracic lymph nodes (code A15.4) Kidneys (code A18.11) Bones and joints (subcategory A18.0) Miliary tuberculosis (category A19): bacillus spreads through all body tissues and organs, producing many thousands of tiny tubercular lesions.