ICD-10-CM Tabular List Of Diseases And Injuries

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Chapter 1. Certain Infectious and Parasitic Diseases (A00–B99)Chapter Specific Guidelines with Coding ExamplesThe chapter specific guidelines from the ICD-10-CM Official Guidelines forCoding and Reporting have been provided below. Along with these guidelinesare coding examples, contained in the shaded boxes, that have been developedto help illustrate the coding and/or sequencing guidance found in theseguidelines.a. Human immunodeficiency virus (HIV) infections1) Code only confirmed casesCode only confirmed cases of HIV infection/illness. This is an exception tothe hospital inpatient guideline Section II, H.In this context, “confirmation” does not require documentation of positiveserology or culture for HIV; the provider’s diagnostic statement that thepatient is HIV positive, or has an HIV-related illness is sufficient.Patient being seen for hypothyroidism with possible HIV infectionE03.9Hypothyroidism, unspecifiedExplanation: Only the hypothyroidism is coded in this scenario becauseit has not been confirmed that an HIV infection is present.2) Selection and sequencing of HIV codes(a) Patient admitted for HIV-related conditionIf a patient is admitted for an HIV-related condition, the principaldiagnosis should be B20, Human immunodeficiency virus [HIV]disease followed by additional diagnosis codes for all reportedHIV-related conditions.HIV with CMVB20Human immunodeficiency virus [HIV] diseaseB25.9Cytomegaloviral disease, unspecifiedExplanation: Cytomegaloviral infection is an HIV related condition,so the HIV diagnosis code is reported first, followed by the codefor the CMV.(b) Patient with HIV disease admitted for unrelated conditionIf a patient with HIV disease is admitted for an unrelated condition(such as a traumatic injury), the code for the unrelated condition (e.g.,the nature of injury code) should be the principal diagnosis. Otherdiagnoses would be B20 followed by additional diagnosis codes for allreported HIV-related conditions.Sprain of the internal collateral ligament, right ankle; HIVS93.491ASprain of other ligament of right ankle, initialencounterB20Human immunodeficiency virus [HIV] diseaseExplanation: The ankle sprain is not related to HIV, so it is thefirst-listed diagnosis code, and HIV is reported secondarily.(c) Whether the patient is newly diagnosedWhether the patient is newly diagnosed or has had previousadmissions/encounters for HIV conditions is irrelevant to thesequencing decision.Newly diagnosed multiple cutaneous Kaposi’s sarcoma lesions inpreviously diagnosed HIV diseaseB20Human immunodeficiency virus [HIV] diseaseC46.0Kaposi’s sarcoma of skinExplanation: Even though the HIV was diagnosed on a previousencounter, it is still sequenced first when coded with an HIVrelated condition. Kaposi’s sarcoma is an HIV-related condition.ICD-10-CM 2018(d) Asymptomatic human immunodeficiency virusZ21, Asymptomatic human immunodeficiency virus [HIV] infectionstatus, is to be applied when the patient without any documentationof symptoms is listed as being “HIV positive,” “known HIV,” “HIV testpositive,” or similar terminology. Do not use this code if the term“AIDS” is used or if the patient is treated for any HIV-related illness or isdescribed as having any condition(s) resulting from his/her HIVpositive status; use B20 in these cases.Patient is being seen for iron deficiency anemia. Status positiveHIV test on Atripla, with no prior symptomsD50.9Iron deficiency anemia, unspecifiedZ21Asymptomatic human immunodeficiency virus[HIV] infection statusExplanation: Code Z21 is sequenced second since documentationindicates that the patient has had a positive HIV test but has beenasymptomatic. Being on medication for HIV is not an indicationthat code B20 is used instead of Z21. Unless there has beendocumentation that the patient has had current or priorsymptoms or HIV-related complications, code B20 is not used. Theanemia is not an AIDS-related complication and is sequenced first.(e) Patients with inconclusive HIV serologyPatients with inconclusive HIV serology, but no definitive diagnosis ormanifestations of the illness, may be assigned code R75, Inconclusivelaboratory evidence of human immunodeficiency virus [HIV].(f) Previously diagnosed HIV-related illnessPatients with any known prior diagnosis of an HIV-related illnessshould be coded to B20. Once a patient has developed an HIV-relatedillness, the patient should always be assigned code B20 on everysubsequent admission/encounter. Patients previously diagnosed withany HIV illness (B20) should never be assigned to R75 or Z21,Asymptomatic human immunodeficiency virus [HIV] infection status.(g) HIV infection in pregnancy, childbirth and the puerperiumDuring pregnancy, childbirth or the puerperium, a patient admitted(or presenting for a health care encounter) because of an HIV-relatedillness should receive a principal diagnosis code of O98.7-, Humanimmunodeficiency [HIV] disease complicating pregnancy, childbirthand the puerperium, followed by B20 and the code(s) for theHIV-related illness(es). Codes from Chapter 15 always take sequencingpriority.Patients with asymptomatic HIV infection status admitted (orpresenting for a health care encounter) during pregnancy, childbirth,or the puerperium should receive codes of O98.7- and Z21.(h) Encounters for testing for HIVIf a patient is being seen to determine his/her HIV status, use codeZ11.4, Encounter for screening for human immunodeficiency virus[HIV]. Use additional codes for any associated high risk behavior.If a patient with signs or symptoms is being seen for HIV testing, codethe signs and symptoms. An additional counseling code Z71.7, Humanimmunodeficiency virus [HIV] counseling, may be used if counseling isprovided during the encounter for the test.When a patient returns to be informed of his/her HIV test results andthe test result is negative, use code Z71.7, Human immunodeficiencyvirus [HIV] counseling.If the results are positive, see previous guidelines and assign codes asappropriate.b. Infectious agents as the cause of diseases classified to other chaptersCertain infections are classified in chapters other than Chapter 1 and noorganism is identified as part of the infection code. In these instances, it isnecessary to use an additional code from Chapter 1 to identify the organism.A code from category B95, Streptococcus, Staphylococcus, and Enterococcusas the cause of diseases classified to other chapters, B96, Other bacterialagents as the cause of diseases classified to other chapters, or B97, Viralagents as the cause of diseases classified to other chapters, is to be used as anadditional code to identify the organism. An instructional note will be foundat the infection code advising that an additional organism code is required.433Chapter 1. Certain Infectious and Parasitic DiseasesICD-10-CM Tabular List of Diseases and Injuries

Chapter 1. Certain Infectious and Parasitic DiseasesGuidelines and ExamplesChapter 1. Certain Infectious and Parasitic DiseasesAcute E. coli cystitisSepsis and acute respiratory failure due to COPD exacerbationN30.00Acute cystitis without hematuriaA41.9Sepsis, unspecified organismB96.20Unspecified Escherichia coli [E.coli] as the cause ofdiseases classified elsewhereJ44.1Chronic obstructive pulmonary disease with(acute) exacerbationJ96.00Acute respiratory failure, unspecified whetherwith hypoxia or hypercapniaExplanation: An instructional note under the category for the cystitisindicates to code also the specific organism.c. Infections resistant to antibioticsMany bacterial infections are resistant to current antibiotics. It is necessary toidentify all infections documented as antibiotic resistant. Assign a code fromcategory Z16, Resistance to antimicrobial drugs, following the infection codeonly if the infection code does not identify drug resistance.Penicillin-resistant Streptococcus pneumoniae pneumoniaJ13Pneumonia due to Streptococcus pneumoniaeZ16.11Resistance to penicillinsExplanation: Code Z16.11 is assigned as a secondary code to represent thepenicillin resistance. This code includes resistance to amoxicillin andampicillin.d. Sepsis, severe sepsis, and septic shock1) Coding of Sepsis and Severe Sepsis(a) SepsisFor a diagnosis of sepsis, assign the appropriate code for theunderlying systemic infection. If the type of infection or causalorganism is not further specified, assign code A41.9, Sepsis,unspecified organism.A code from subcategory R65.2, Severe sepsis, should not be assignedunless severe sepsis or an associated acute organ dysfunction isdocumented.Explanation: Although acute organ dysfunction is present in theform of acute respiratory failure, severe sepsis (R65.2) is notcoded in this example, as the acute respiratory failure isattributed to the COPD exacerbation rather than the sepsis.Sequencing of these codes would be determined by the reasonfor the encounter.(b) Severe sepsisThe coding of severe sepsis requires a minimum of 2 codes: first a codefor the underlying systemic infection, followed by a code fromsubcategory R65.2, Severe sepsis. If the causal organism is notdocumented, assign code A41.9, Sepsis, unspecified organism, for theinfection. Additional code(s) for the associated acute organdysfunction are also required.Due to the complex nature of severe sepsis, some cases may requirequerying the provider prior to assignment of the codes.2) Septic shock(a) Septic shock generally refers to circulatory failure associated withsevere sepsis, and therefore, it represents a type of acute organdysfunction.For cases of septic shock, the code for the systemic infection should besequenced first, followed by code R65.21, Severe sepsis with septicshock or code T81.12, Postprocedural septic shock. Any additionalcodes for the other acute organ dysfunctions should also be assigned.As noted in the sequencing instructions in the Tabular List, the codefor septic shock cannot be assigned as a principal diagnosis.Gram-negative sepsisSepsis with septic shockA41.50Gram-negative sepsis, unspecifiedA41.9Sepsis, unspecified organismStaphylococcal sepsisR65.21Severe sepsis with septic shockA41.2Explanation: Documentation of septic shock automatically impliessevere sepsis as it is a form of acute organ dysfunction. Septicshock is not coded as the first-listed diagnosis; it is alwayspreceded by the code for the systemic infection.Sepsis due to unspecified staphylococcusExplanation: In both examples above the organism causing thesepsis is identified, therefore A41.9 Sepsis, unspecified organism,would not be appropriate as this code would not capture the highestdegree of specificity found in the documentation. Do not use anadditional code for severe sepsis unless an acute organ dysfunctionwas also documented as “associated with” or “due to” the sepsis orthe sepsis was documented as “severe.”(i) Negative or inconclusive blood cultures and sepsisNegative or inconclusive blood cultures do not preclude adiagnosis of sepsis in patients with clinical evidence of thecondition; however, the provider should be queried.(ii) UrosepsisThe term urosepsis is a nonspecific term. It is not to be consideredsynonymous with sepsis. It has no default code in the AlphabeticIndex. Should a provider use this term, he/she must be queried forclarification.(iii)Sepsis with organ dysfunctionIf a patient has sepsis and associated acute organ dysfunction ormultiple organ dysfunction (MOD), follow the instructions forcoding severe sepsis.(iv) Acute organ dysfunction that is not clearly associated withthe sepsisIf a patient has sepsis and an acute organ dysfunction, but themedical record documentation indicates that the acute organdysfunction is related to a medical condition other than the sepsis,do not assign a code from subcategory R65.2, Severe sepsis. Anacute organ dysfunction must be associated with the sepsis inorder to assign the severe sepsis code. If the documentation is notclear as to whether an acute organ dysfunction is related to thesepsis or another medical condition, query the provider.434ICD-10-CM 20183) Sequencing of severe sepsisIf severe sepsis is present on admission, and meets the definition ofprincipal diagnosis, the underlying systemic infection should be assignedas principal diagnosis followed by the appropriate code from subcategoryR65.2 as required by the sequencing rules in the Tabular List. A code fromsubcategory R65.2 can never be assigned as a principal diagnosis.When severe sepsis develops during an encounter (it was not present onadmission), the underlying systemic infection and the appropriate codefrom subcategory R65.2 should be assigned as secondary diagnoses.Severe sepsis may be present on admission, but the diagnosis may not beconfirmed until sometime after admission. If the documentation is notclear whether severe sepsis was present on admission, the providershould be queried.4) Sepsis and severe sepsis with a localized infectionIf the reason for admission is both sepsis or severe sepsis and a localizedinfection, such as pneumonia or cellulitis, a code(s) for the underlyingsystemic infection should be assigned first and the code for the localizedinfection should be assigned as a secondary diagnosis. If the patient hassevere sepsis, a code from subcategory R65.2 should also be assigned as asecondary diagnosis. If the patient is admitted with a localized infection,such as pneumonia, and sepsis/severe sepsis doesn’t develop until afteradmission, the localized infection should be assigned first, followed bythe appropriate sepsis/severe sepsis codes.ICD-10-CM 2018

ICD-10-CM 2018Chapter 1. Certain Infectious and Parasitic DiseasesA41.52Sepsis, due to PseudomonasJ15.1Pneumonia due to PseudomonasR65.20Severe sepsis without septic shockN17.9Acute kidney failure, unspecifiedExplanation: If all conditions are present, the systemic infection (sepsis)is sequenced first followed by the codes for the localized infection(pneumonia), severe sepsis and any organ dysfunction.5) Sepsis due to a postprocedural infectio