Infectious and Parasitic Diseases: (ICD-9-CM Chapter 1, Codes 001-139, and ICD-10-CM Chapter 1, Codes A00-B99)



Infectious and Parasitic Diseases


(ICD-9-CM Chapter 1, Codes 001-139, and ICD-10-CM Chapter 1, Codes A00-B99)



Learning Objectives



1. Apply and assign the correct ICD-9-CM and ICD-10-CM codes in accordance with Official Guidelines for Coding and Reporting


2. Identify major differences between ICD-9-CM and ICD-10-CM related to infectious and parasitic diseases


3. Recognize infectious and parasitic diseases


4. Assign the correct V codes and procedure codes related to infectious and parasitic diseases


5. Identify common treatments, medications, laboratory values, and diagnostic tests


6. Explain the importance of documentation as it relates to MS-DRGs for reimbursement



Abbreviations/Acronyms






























ICD-9-CM Official Guidelines for Coding and Reporting


Please refer to the companion Evolve website for the most current guidelines.




1. Chapter 1: Infectious and Parasitic Diseases (001-139)



a. Human Immunodeficiency Virus (HIV) Infections



1) Code only confirmed cases


    Code only confirmed cases of HIV infection/illness. This is an exception of the hospital inpatient guideline Section II, H.


    In this context, “confirmation” does not require documentation of positive serology or culture for HIV; the provider’s diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient.



Example


Patient with possible human immunodeficiency virus (HIV). Even though in the inpatient setting it is acceptable to code diagnoses that are possible or suspected, in the case of possible HIV, you would not assign 042. You would have to query the physician regarding the patient’s exact HIV status. This is one of the only exceptions to coding a diagnosis as if it exists when it is documented as possible or probable.


2) Selection and sequencing of HIV codes



(a) Patient admitted for HIV-related condition


    If a patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV-related conditions.



Example


The patient was admitted for treatment of Kaposi’s sarcoma of the skin. The patient’s HIV has been symptomatic for the past year, 042, 176.0 (B20, C46.0).


(b) Patient with HIV disease admitted for unrelated condition


    If 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. Other diagnoses would be 042 followed by additional diagnosis codes for all reported HIV-related conditions.



Example


Initial encounter for traumatic closed-fracture of the left femoral shaft in a patient who has acquired immunodeficiency syndrome (AIDS) patient fell down the stairs, 821.00, 042, E887 (S72.302A, B20, W10.9xxA).


(c) Whether the patient is newly diagnosed


    Whether the patient is newly diagnosed or has had previous admissions/encounters for HIV conditions is irrelevant to the sequencing decision.


(d) Asymptomatic human immunodeficiency virus


    V08 Asymptomatic human immunodeficiency virus [HIV] infection, is to be applied when the patient without any documentation of symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” 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 is described as having any condition(s) resulting from his/her HIV positive status; use 042 in these cases.



Example


The patient’s HIV test last week was positive; the patient is asymptomatic, V08 (Z21).


(e) Patients with inconclusive HIV serology


    Patients with inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness, may be assigned code 795.71, Inconclusive serologic test for Human Immunodeficiency Virus [HIV].


(f) Previously diagnosed HIV-related illness


    Patients with any known prior diagnosis of an HIV-related illness should be coded to 042. Once a patient had developed an HIV-related illness, the patient should always be assigned code 042 on every subsequent admission/encounter. Patients previously diagnosed with any HIV illness (042) should never be assigned to 795.71 or V08.



Example


HIV patient with prior history of Pneumocystis carinii pneumonia (PCP), 042 (B20). PCP is an opportunistic lung infection that has been identified as an AIDS-defining illness.


(g) HIV Infection in Pregnancy, Childbirth and the Puerperium


    During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of an HIV-related illness should receive a principal diagnosis of 647.6X, Other specified infectious and parasitic diseases in the mother classifiable elsewhere, but complicating the pregnancy, childbirth or the puerperium, followed by 042 and the code(s) for the HIV-related illness(es). Codes from Chapter 15 always take sequencing priority.



Example


The patient is 20 weeks pregnant and is admitted for treatment of esophageal candidiasis due to AIDS, 647.63, 042, 112.84 (098.712, B2O, B37.81).


    Patients with asymptomatic HIV infection status admitted (or presenting for a health care encounter) during pregnancy, childbirth, or the puerperium should receive codes of 647.6X and V08.



Example


A patient at 39 weeks delivered liveborn twins vaginally during her hospital stay. The mother’s HIV has remained asymptomatic, 651.01, 647.61, V08, V27.2, 73.59 (O30.003, O98.72, Z21, Z37.2, 10E0XZZ).


(h) Encounters for testing for HIV


    If a patient is being seen to determine his/her HIV status, use code V73.89, Screening for other specified viral disease. Use code V69.8, Other problems related to lifestyle, as a secondary code if an asymptomatic patient is in a known high risk group for HIV. Should a patient with signs or symptoms or illness, or a confirmed HIV related diagnosis be tested for HIV, code the signs and symptoms or the diagnosis. An additional counseling code V65.44 may be used if counseling is provided during the encounter for the test.


    When a patient returns to be informed of his/her HIV test results use code V65.44, HIV counseling, if the results of the test are negative.


    If the results are positive but the patient is asymptomatic use code V08, Asymptomatic HIV infection. If the results are positive and the patient is symptomatic use code 042, HIV infection, with codes for the HIV related symptoms or diagnosis. The HIV counseling code may also be used if counseling is provided for patients with positive test results.



Example


Because of high-risk homosexual behavior, the patient is seen in the clinic for HIV screening, V73.89, V69.2 (Z11.4, Z72.52).



Example


The patient returns for test results that are negative and is counseled regarding HIV prevention, V65.44 (Z71.7).



Example


The patient returns for test results that are positive, and the patient is asymptomatic. She is instructed regarding symptoms to watch for and means of prevention, V08, V65.44 (Z21, Z71.7).


b. Septicemia, Systemic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, and Septic Shock



1) SIRS, Septicemia, and Sepsis



(a) The terms septicemia and sepsis are often used interchangeably by providers, however they are not considered synonymous terms. The following descriptions are provided for reference but do not preclude querying the provider for clarification about terms used in the documentation:



(b) The coding of SIRS, Sepsis and severe Sepsis


    The coding of SIRS, sepsis and severe sepsis requires a minimum of 2 codes: a code for the underlying cause (such as infection or trauma) and a code from subcategory 995.9 Systemic inflammatory response syndrome (SIRS).



(i) The code for the underlying cause (such as infection or trauma) must be sequenced before the code from subcategory 995.9 Systemic inflammatory response syndrome (SIRS).


(ii) Sepsis and severe sepsis require a code for the systemic infection (038.xx, 112.5, etc.) and either code 995.91, Sepsis, or 995.92, Severe sepsis. If the causal organism is not documented, assign code 038.9, Unspecified septicemia.


(iii) Severe sepsis requires additional code(s) for the associated acute organ dysfunction(s).


(iv) If a patient has sepsis with multiple organ dysfunctions, follow the instructions for coding severe sepsis.


(v) Either the term sepsis or SIRS must be documented to assign a code from subcategory 995.9.


(vi) See Section I.C.17.g.), Injury and poisoning, for information regarding systemic inflammatory response syndrome (SIRS) due to trauma/burns and other non-infectious processes.


(c) Due to the complex nature of sepsis and severe sepsis, some cases may require querying the provider prior to assignment of the codes.


2) Sequencing sepsis and severe sepsis



(a) Sepsis and severe sepsis as principal diagnosis


    If sepsis or severe sepsis is present on admission, and meets the definition of principal diagnosis, the systemic infection code (e.g., 038.xx, 112.5, etc) should be assigned as the principal diagnosis, followed by code 995.91, Sepsis, or 995.92, Severe sepsis, as required by the sequencing rules in the Tabular List. Codes from subcategory 995.9 can never be assigned as a principal diagnosis. A code should also be assigned for any localized infection, if present.


    If the sepsis or severe sepsis is due to a postprocedural infection, see Section I.C.10 for guidelines related to sepsis due to postprocedural infection.



Example


The patient was admitted and treated for SIRS with sepsis due to streptococcus, group D; the patient has cellulitis of the right leg, 038.0, 995.91, 682.6 (A41.81, L03.115).


(b) Sepsis and severe sepsis as secondary diagnoses


    When sepsis or severe sepsis develops during the encounter (it was not present on admission), the systemic infection code and code 995.91 or 995.92 should be assigned as secondary diagnoses.



Example


The patient was admitted with pneumonia due to Staphylococcus aureus. Two days after admission, the patient developed signs of sepsis due to the staph infection, 482.41, 038.11, 995.91 (J15.211, A41.01).


(c) Documentation unclear as to whether sepsis or severe sepsis is present on admission


    Sepsis or severe sepsis may be present on admission but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether the sepsis or severe sepsis was present on admission, the provider should be queried.


3) Sepsis/SIRS with Localized Infection


    If the reason for admission is both sepsis, severe sepsis, or SIRS and a localized infection, such as pneumonia or cellulitis, a code for the systemic infection (038.xx, 112.5, etc) should be assigned first, then code 995.91 or 995.92, followed by the code for the localized infection. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/SIRS doesn’t develop until after admission, see guideline I.C.1.b.2.b).


    If the localized infection is postprocedural, see Section I.C.10 for guidelines related to sepsis due to postprocedural infection.



Example


The patient was admitted with pneumonia due to Staphylococcus aureus and sepsis due to staph infection, 038.11, 482.41, 995.91 (A41.01, J15.211).


    Note: The term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism if known.



Example


The patient was treated for UTI due to E. coli, 599.0, 041.49, (N39.0, B96.20).


4) Bacterial Sepsis and Septicemia


    In most cases, it will be a code from category 038, Septicemia, that will be used in conjunction with a code from subcategory 995.9 such as the following:



5) Acute organ dysfunction that is not clearly associated with the sepsis


    If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign code 995.92, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.



Example


The patient was admitted in acute respiratory failure due to Staphylococcus aureus pneumonia. The patient also presented with sepsis due to staph infection associated with respiratory failure, 038.11, 482.41, 995.92, 518.81 (A41.01, J15.211, J96.00, R65.20).


6) Septic shock



(a) Sequencing of septic shock and postprocedural septic shock


    Septic shock generally refers to circulatory failure associated with severe sepsis, and, therefore, it represents a type of acute organ dysfunction.


    For cases of septic shock, the code for the systemic infection should be sequenced first, followed by codes 995.92, Severe sepsis and 785.52, Septic shock or 998.02, Postoperative septic shock. Any additional codes for other acute organ dysfunctions should also be assigned. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis.



Example


The patient was admitted with pneumonia due to Staphylococcus aureus. Several days after admission, the patient developed septic shock due to Staphylococcus sepsis, 482.41, 038.11, 995.92, 785.52 (J15.211, A41.01, R65.21).


(b) Septic shock and postprocedural septic shock without documentation of severe sepsis


    Since septic shock indicates the presence of severe sepsis, code 995.92, Severe sepsis, can be assigned with code 785.52, Septic shock, or code 998.02 Postoperative shock, septic, even if the term severe sepsis is not documented in the record.


image
Figure 9-1 Tabular entry for septic shock.


Example


The patient was admitted with septic shock and acute renal failure caused by a UTI due to E. coli. Discharge summary documents sepsis due to E. Coli, 038.42, 995.92, 584.9, 785.52, 599.0 (A41.51, N39.0, R65.21, N17.9).


7) Sepsis and septic shock complicating abortion and pregnancy


    Sepsis and septic shock complicating abortion, ectopic pregnancy, and molar pregnancy are classified to category codes in Chapter 11 (630-639).


    See section I.C.11.


8) Negative or inconclusive blood cultures


    Negative or inconclusive blood cultures do not preclude a diagnosis of septicemia or sepsis in patients with clinical evidence of the condition, however, the provider should be queried.


9) Newborn sepsis


    See Section I.C.15.j. for information on the coding of newborn sepsis.


10) Sepsis due to a Postprocedural Infection



(a) Documentation of causal relationship


    As with all postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the infection and the procedure.


(b) Sepsis due to postprocedural infection


    In cases of postprocedural sepsis, the complication code, such as code 998.59, Other postoperative infection, or 674.3x, Other complications of obstetrical surgical wounds should be coded first followed by the appropriate sepsis codes (systemic infection code and either code 995.91 or 995.92). An additional code(s) for any acute organ dysfunction should also be assigned for cases of severe sepsis.


    See Section I.C.l.b.6 if the sepsis or severe sepsis results in postprocedural septic shock.


(c) Postprocedural infection and postprocedural septic shock


    In cases where a postprocedural infection has occurred and has resulted in severe sepsis and postprocedural septic shock, the code for the precipitating complication such as code 998.59, Other postoperative infection, or 674.3x, Other complications of obstetrical surgical wounds should be coded first followed by the appropriate sepsis codes (systemic infection code and code 995.92). Code 998.02, Postoperative septic shock, should be assigned as an additional code. In cases of severe sepsis, an additional code(s) for any acute organ dysfunction should also be assigned.


11) External cause of injury codes with SIRS


    Refer to Section I.C.19.a.7 for instruction on the use of external cause of injury codes with codes for SIRS resulting from trauma.


12) Sepsis and Severe Sepsis Associated with Non-infectious Process


    In some cases, a non-infectious process, 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 noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced first, followed by the code for the systemic infection and either code 995.91, Sepsis, or 995.92, Severe sepsis. Additional codes for any associated acute organ dysfunction(s) should also be assigned for cases of severe sepsis. If the sepsis or severe sepsis meets the definition of principal diagnosis, the systemic infection and sepsis codes should be sequenced before the noninfectious condition. When both the associated non-infectious condition and the sepsis or severe sepsis meet the definition of principal diagnosis, either may be assigned as principal diagnosis.


    See Section I.C.1.b.2) (a) for guidelines pertaining to sepsis or severe sepsis as the principal diagnosis.


    Only one code from subcategory 995.9 should be assigned. Therefore, when a non-infectious condition leads to an infection resulting in sepsis or severe sepsis, assign either code 995.91 or 995.92. Do not additionally assign code 995.93, Systemic inflammatory response syndrome due to non-infectious process without acute organ dysfunction, or 995.94, Systemic inflammatory response syndrome with acute organ dysfunction.


    See Section I.C.17.g for information on the coding of SIRS due to trauma/burns or other noninfectious disease processes.


c. Methicillin Resistant Staphylococcus aureus (MRSA) Conditions



1) Selection and sequencing of MRSA codes



(a) Combination codes for MRSA infection


    When a patient is diagnosed with an infection that is due to methicillin resistant Staphylococcus aureus (MRSA), and that infection has a combination code that includes the causal organism (e.g., septicemia, pneumonia) assign the appropriate code for the condition (e.g., code 038.12, Methicillin resistant Staphylococcus aureus septicemia or code 482.42, Methicillin resistant pneumonia due to Staphylococcus aureus). Do not assign code 041.12, Methicillin resistant Staphylococcus aureus, as an additional code because the code includes the type of infection and the MRSA organism. Do not assign a code from subcategory V09.0, Infection with microorganisms resistant to penicillins, as an additional diagnosis.


    See Section C.1.b.1 for instructions on coding and sequencing of septicemia.



Example


Patient presents to the hospital with a high fever. Pneumonia is identified on a chest x-ray. Sputum cultures are positive for MRSA. On the discharge summary, the physician documents that patient had pneumonia due to MRSA, 482.42 (J15.212).


(b) Other codes for MRSA infection


    When there is documentation of a current infection (e.g., wound infection, stitch abscess, urinary tract infection) due to MRSA, and that infection does not have a combination code that includes the causal organism, select the appropriate code to identify the condition along with code 041.12, Methicillin resistant Staphylococcus aureus, for the MRSA infection. Do not assign a code from subcategory V09.0, Infection with microorganisms resistant to penicillins.



Example


Patient presents to the hospital with an abscess under their left (axilla) arm. It is cultured and grows MRSA. Physician documents that the abscess is due to MRSA, 682.3, 041.12 (L02.412, B95.62).


(c) Methicillin susceptible Staphylococcus aureus (MSSA) and MRSA colonization


    The condition or state of being colonized or carrying MSSA or MRSA is called colonization or carriage, while an individual person is described as being colonized or being a carrier. Colonization means that MSSA or MSRA is present on or in the body without necessarily causing illness. A positive MRSA colonization test might be documented by the provider as “MRSA screen positive” or “MRSA nasal swab positive”.


    Assign code V02.54, Carrier or suspected carrier, Methicillin resistant Staphylococcus aureus, for patients documented as having MRSA colonization. Assign code V02.53, Carrier or suspected carrier, Methicillin susceptible Staphylococcus aureus, for patient documented as having MSSA colonization. Colonization is not necessarily indicative of a disease process or as the cause of a specific condition the patient may have unless documented as such by the provider.


    Code V02.59, Other specified bacterial diseases, should be assigned for other types of staphylococcal colonization (e.g., S. epidermidis, S. saprophyticus). Code V02.59 should not be assigned for colonization with any type of Staphylococcus aureus (MRSA, MSSA).



Example


Due to recent outbreak of MRSA, every patient coming through the Emergency Room has a nasal swab taken to check for carrier status. Patient’s swab returns positive for MRSA, V02.54 (Z22.32, Z22.322).


(d) MRSA colonization and infection


    If a patient is documented as having both MRSA colonization and infection during a hospital admission, code V02.54, Carrier or suspected carrier, Methicillin resistant Staphylococcus aureus, and a code for the MRSA infection may both be assigned.



Example


Patient presents to the hospital with an abscess on the buttock. A culture of the abscess is taken as well as a nasal swab. The culture returns positive for MRSA as well as a positive nasal swab. The physician documents that the abscess is due to MRSA, 682.5, 041.12, V02.54 (L02.31, B95.62, Z22.322).


Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Guidelines as found in Chapter 6.



ICD-10-CM Official Guidelines for Coding and Reporting


Please refer to the companion Evolve website for the most current guidelines.




1. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)



a. Human Immunodeficiency Virus (HIV) Infections



1) Code only confirmed cases


    Code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H.


    In this context, “confirmation” does not require documentation of positive serology or culture for HIV; the provider’s diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient.


2) Selection and sequencing of HIV codes



(a) Patient admitted for HIV-related condition


    If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related conditions.


(b) Patient with HIV disease admitted for unrelated condition


    If 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. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions.


(c) Whether the patient is newly diagnosed


    Whether the patient is newly diagnosed or has had previous admissions/encounters for HIV conditions is irrelevant to the sequencing decision.


(d) Asymptomatic human immunodeficiency virus


    Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” 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 is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases.


(e) Patients with inconclusive HIV serology


    Patients with inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness, may be assigned code R75, Inconclusive laboratory evidence of human immunodeficiency virus [HIV].


(f) Previously diagnosed HIV-related illness


    Patients with any known prior diagnosis of an HIV-related illness should be coded to B20. Once a patient has developed an HIV-related illness, the patient should always be assigned code B20 on every subsequent admission/encounter. Patients previously diagnosed with any 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 Puerperium


    During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of an HIV-related illness should receive a principal diagnosis code of O98.7-, Human immunodeficiency [HIV] disease complicating pregnancy, childbirth and the puerperium, followed by B20 and the code(s) for the HIV-related illness(es). Codes from Chapter 15 always take sequencing priority.


    Patients with asymptomatic HIV infection status admitted (or presenting for a health care encounter) during pregnancy, childbirth, or the puerperium should receive codes of O98.7- and Z21.


(h) Encounters for testing for HIV


    If a patient is being seen to determine his/her HIV status, use code Z11.4, 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, code the signs and symptoms. An additional counseling code Z71.7, Human innunodeficiency virus [HIV] counseling, may be used if counseling is provided during the encounter for the test.


    When a patient returns to be informed of his/her HIV test results and the test result is negative, use code Z71.7, Human immunodeficiency virus [HIV] counseling.


    If the results are positive, see previous guidelines and assign codes as appropriate.


b. Infectious agents as the cause of diseases classified to other chapters


    Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code. In these instances, it is necessary to use an additional code from Chapter 1 to identify the organism. A code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified to other chapters, B96, Other bacterial agents as the cause of diseases classified to other chapters, or B97, Viral agents as the cause of diseases classified to other chapters, is to be used as an additional code to identify the organism. An instructional note will be found at the infection code advising that an additional organism code is required.


c. Infections resistant to antibiotics


    Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant. Assign a code from category Zl6, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.


d. Sepsis, Severe Sepsis, and Septic Shock



1) Coding of Sepsis and Severe Sepsis



(a) Sepsis


    For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.


    A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.



(i) Negative or inconclusive blood cultures and sepsis


    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.


(ii) Urosepsis


    The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.


(iii) Sepsis with organ dysfunction


    If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding severe sepsis.


(iv) Acute organ dysfunction that is not clearly associated with the sepsis


    If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.


(b) Severe sepsis


    The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified, for the infection. Additional code(s) for the associated acute organ dysfunction are also required.


    Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.


2) Septic shock



3) Sequencing of severe sepsis


    If severe sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. A code from subcategory R65.2 can never be assigned as a principal diagnosis.


    When severe sepsis develops during an encounter (it was not present on admission) the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses.


    Severe sepsis may be present on admission but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether severe sepsis was present on admission, the provider should be queried.


4) Sepsis and severe sepsis with a localized infection


    If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn’t develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes.


5) Sepsis due to a postprocedural infection



(a) Documentation of causal relationship


    As with all postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the infection and the procedure.


(b) Sepsis due to a postprocedural infection


    For such cases, the postprocedural infection code, such as, T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or 086.0, Infection of obstetric surgical wound, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.


(c) Postprocedural infection and postprocedural septic shock


    In cases where a postprocedural infection has occurred and has resulted in severe sepsis and postprocedural septic shock, the code for the precipitating complication such as code T81.4, Infection following a procedure, or 086.0, Infection of obstetrical surgical wound should be coded first followed by code R65.21, Severe sepsis with septic shock and a code for the systemic infection.


6) Sepsis and severe sepsis associated with a noninfectious process (condition)


    In some cases a noninfectious 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 noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced 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.


    If the infection meets the definition of principal diagnosis it should be sequenced before 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 principal diagnosis.


    Only one code from category R65, Symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. Therefore, when a non-infectious 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.


    See Section I.C.18. SIRS due to non-infectious process


7) Sepsis and septic shock complicating abortion, pregnancy, childbirth, and the puerperium


    See Section I.C.15. Sepsis and septic shock complicating abortion, pregnancy, childbirth and the puerperium


8) Newborn sepsis


    See Section I.C.16. Newborn sepsis

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  2. Diseases of the Respiratory System: (ICD-9-CM Chapter 8, Codes 460-519, and ICD-10-CM Chapter 10, Codes J00-J99)
  3. Diseases of the Circulatory System: (ICD-9-CM Chapter 7, Codes 390-459, and ICD-10-CM Chapter 9, Codes I00-I99)
  4. Introduction to ICD-10-PCS

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Jun 14, 2017 | Posted by in GENERAL SURGERY | Comments Off on Infectious and Parasitic Diseases: (ICD-9-CM Chapter 1, Codes 001-139, and ICD-10-CM Chapter 1, Codes A00-B99)

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