1. The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 11 Coding Infectious Diseases Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

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 - 2

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 - 3

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 - 4

5. HIV Infections ·Only code this or any other condition when clearly specified in the physician’s notes. 11 - 5

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 - 6

7. HIV Infections ·Test Positive: ·When the patient is asymptomatic, use V08 Asymptomatic human immunodeficiency virus [HIV] infection status. 11 - 7

8. HIV Infections ·Test Positive: ·When the patient has symptoms or manifestations, use 042 Human immunodeficiency virus [HIV] disease. 11 - 8

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 - 9

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 - 10

11. Blood Infections ·Bacteremia: An abnormal blood culture ·Septicemia: Blood infection, generalized 11 - 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 - 12

13. Blood Infections ·Pathogen: An identified cause of infection or disease; bacteria or virus 11 - 13

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 - 14

15. Blood Infections ·Septicemia ·038.x ·Sepsis (Septicemia + SIRS) ·038.x + 995.9x ·Severe Sepsis ·038.x + 995.9x + code for organ failure 11 - 15

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 - 16

17. Blood Infections ·SIRS without Infection: ·Code the underlying condition ·+ 995.9x ·+ code for organ dysfunction, when applicable 11 - 17

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 - 18

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 - 19

20. Other Infections ·Viral hepatitis, type A ·Viral hepatitis, type B ·Meningitis (viral or bacterial) ·Tetanus (lockjaw) ·Influenza (flu) ·Sexually transmitted diseases (STDs) 11 - 20

21. Other Infections ·Varicella (chicken pox) ·Rubeola (measles) ·Rubella (German measles) ·Mumps ·Parasitic infections 11 - 21

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. 11 - 22