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 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. 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. 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. 11 - 5 HIV Infections · Only code this or any other condition when clearly specified in the physician’s notes. 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. 11 - 7 HIV Infections · Test Positive: · When the patient is asymptomatic, use V08 Asymptomatic human immunodeficiency virus [HIV] infection status. 11 - 8 HIV Infections · Test Positive: · When the patient has symptoms or manifestations, use 042 Human immunodeficiency virus [HIV] disease. 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. 11 - 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 - 11 Blood Infections · Bacteremia: An abnormal blood culture · Septicemia: Blood infection, generalized 11 - 12 Blood Infections · Signs and symptoms include: · Increased body temperature (fever) · Change in heart rate · Change in respiratory rate · Increased white cell count 11 - 13 Blood Infections · Pathogen: An identified cause of infection or disease; bacteria or virus 11 - 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 11 - 15 Blood Infections · Septicemia · 038.x · Sepsis (Septicemia + SIRS) · 038.x + 995.9x · Severe Sepsis · 038.x + 995.9x + code for organ failure 11 - 16 Blood Infections · Septic Shock Codes: · 038.x · + 995.92 or 995.94 · + code for septic shock such as 785.52 · + code for organ dysfunction 11 - 17 Blood Infections · SIRS without Infection: · Code the underlying condition · + 995.9x · + code for organ dysfunction, when applicable 11 - 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. 11 - 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) 11 - 20 Other Infections · Viral hepatitis, type A · Viral hepatitis, type B · Meningitis (viral or bacterial) · Tetanus (lockjaw) · Influenza (flu) · Sexually transmitted diseases (STDs) 11 - 21 Other Infections · Varicella (chicken pox) · Rubeola (measles) · Rubella (German measles) · Mumps · Parasitic infections 11 - 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.