1. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. THE COMPLETE DIAGNOSIS CODING SOLUTION THIRD EDITION Chapter 4 Coding Infectious Diseases 4-1

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Outcomes 4.1 Explain differences between bacterial, viral, and parasitic. 4.2 Discuss the impact of communicable diseases. 4.3 Identify the concerns related to reporting HIV infections. 4-2

3. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Outcomes (cont.) 4.4 Distinguish between septicemia and SIRS. 4.5 Interpret correctly documentation about MRSA. 4.6 Code common other infectious and communicable conditions. 4-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Acute Asymptomatic Bacteria Chronic Endemic 4-4

5. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Epidemic Fungi Human immunodeficiency virus (HIV) Infection Infectious 4-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Inflammation Nosocomial Pandemic Parasites Pathogen 4-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Sepsis Septic shock Septicemia Systemic 4-7

8. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Systemic inflammatory response syndrome (SIRS) Tuberculosis Viruses 4-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction Infectious diseases are spread by physical contact, such as a handshake or the exchange of bodily fluids. Others can be spread by inhalation or touching a doorknob that has been handled by an infected person. 4-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Pathogens Any agent that causes disease; a microorganism such as a bacterium or virus. There are many types of pathogens, and each carries its own threat to your health. Learning Outcome: 4.1 4-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Pathogens (cont.) The most common types of pathogens are: Bacteria Viruses Parasites Fungi Learning Outcome: 4.1 4-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Communicable Disease Pathogens can be transmitted by: Touch exposure Airborne exposure Droplet exposure Contact exposure Needlestick/sharps injury exposure Learning Outcome: 4.2 4-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Human Immunodeficiency Virus Infections Only code this condition when clearly specified in the physician’s notes that the patient is HIV-positive. Testing for HIV Exposure: –Z20.6: Contact with and (suspected) exposure to human immunodeficiency virus [HIV] Test Negative for HIV: –Z71.7: HIV test negative – human immunodeficiency virus [HIV] counseling Learning Outcome: 4.3 4-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Human Immunodeficiency Virus Infections (cont.) Test Positive: When the patient is asymptomatic –Z21 Asymptomatic human immunodeficiency virus [HIV] infection status. When the patient has symptoms or manifestations –B20 Human immunodeficiency virus [HIV] disease. Learning Outcome: 4.3 4-14

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Human Immunodeficiency Virus Infections (cont.) Unrelated Conditions: When a patient who has been diagnosed as HIV-positive visits a physician for a concern other than the HIV- positive status, HIV is always included because it is a systemic disease. - S32.3XXA Fracture of coccyx, initial encounter - B20 Human immunodeficiency virus [HIV] Learning Outcome: 4.3 4-15

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Septicemia and Other Blood Infections Septicemia: Generalized infection spread through the body via the bloodstream; blood infection. A serious condition. Bacteremia: The presence of viable bacteria in the circulating blood. Learning Outcome: 4.4 4-16

17. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Septicemia and Other Blood Infections (cont.) Sepsis: Two or more signs and symptoms; a reaction to a specified pathogen. Severe Sepsis: Sepsis + acute organ dysfunction. Systemic Inflammatory Response Syndrome (SIRS): Signs and symptoms of an unknown pathogen Learning Outcome: 4.4 4-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Septicemia and Other Blood Infections (cont.) Septicemia NOS –Use code A41.9 Sepsis with identification of pathogen –Use code category A40.- or A41.- Learning Outcome: 4.4 4-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Septicemia and Other Blood Infections (cont.) Severe Sepsis coding sequence –First code from category A40.- or A41.- for known pathogen or A41.9 for unknown pathogen –Followed by a code from subcatgory R65.2-, severe sepsis –Followed by a code to report specific organ failure Learning Outcome: 4.4 4-19

20. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Septic Shock Coding Sequence First code for the systemic infection Next code for the severe sepsis with septic shock Then code for the organ dysfunction Learning Outcome: 4.4 4-20

21. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. SIRS without Infection First code the underlying condition Next code for SIRS Followed by the code for organ dysfunction, when applicable Learning Outcome: 4.4 4-21

22. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Methicillin-Resistant Staphylococcus Aureus (MRSA) Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial (staph) infection that is essentially unaffected by certain antibiotics. Learning Outcome: 4.5 4-22

23. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. MRSA Colonization -Use code Z22.321 Carrier or suspected carrier, Methicillin susceptible Staphylococcus aureus (MSSA) Or -Z22.322 Carrier or suspected carrier, Methicillin resistant Staphylococcus aureus (MRSA) Learning Outcome: 4.5 4-23

24. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Tuberculosis Does not ONLY affect an individual’s lungs, but can also infect many different anatomical sites. The correct code will identify the specific anatomical site. Learning Outcome: 4.5 4-24

25. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Bacterial Infections Food poisoning is not really a poisoning, but an infection: –Campylobacter –Vibrio –Shigella –Listeria –Salmonella –Clostridium perfringens –Escherichia coli (E. coli) Learning Outcome: 4.5 4-25

26. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Other Infections –Viral hepatitis, type A –Viral hepatitis, type B –Meningitis (viral or bacterial) –Tetanus (lockjaw) –Influenza (flu) –Sexually transmitted diseases (STD) Learning Outcome: 4.6 4-26

27. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Other Infections (cont.) –Varicella (chickenpox) –Rubeola (measles) –Rubella (German measles) –Mumps –Parasitic infections Learning Outcome: 4.6 4-27

28. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. 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. 4-28