ICD 10 CM Chapter Specific Guidelines I. C1

Dr. Lisa L Campbell®

28 Jan 201928:58

EducationalLearning

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TLDRThe video script provides an in-depth guide to ICD-10-CM coding guidelines, focusing on Chapter 1: Certain Infectious and Parasitic Diseases (codes A00-B99). It covers the coding of HIV infections, highlighting the importance of confirming cases and the use of specific codes like B20, Z21, and others for various scenarios. The script also delves into the coding of sepsis and septic shock, emphasizing the need for collaboration with clinicians for accurate documentation and code assignment. Additionally, it addresses the coding of MRSA infections and Zika virus infections, stressing the importance of using the correct codes to reflect the diagnosis and the patient's condition.

Takeaways

📌 HIV coding is primarily focused on confirmed cases, with clinical judgment sufficient for diagnosis without positive serology or culture.
📌 For HIV-related admissions, the primary code is B20, followed by the specific HIV-related condition.
📌 Unrelated conditions to HIV admission are sequenced with the unrelated code first, then B20, and any other HIV-related conditions.
📌 Asymptomatic HIV is coded to Z21, used without documentation of HIV symptoms, and requires consistent coding across visits.
📌 Inconclusive HIV tests utilize code R75, which requires no definitive diagnosis or manifestations of HIV-related illness.
📌 Previously diagnosed HIV patients maintain B20 coding for all encounters, without alternating to other codes like R75 or Z21.
📌 Pregnancy with HIV follows chapter 5 guidelines, giving priority to pregnancy codes (category O99) over other chapters.
📌 HIV testing encounters use Z11.4 for determining HIV status and may include additional codes for high-risk behavior or counseling (Z71.7).
📌 Sepsis coding requires collaboration with clinicians for accurate documentation and code assignment, especially when dealing with severe sepsis and septic shock.
📌 MRSA infections are coded using combination codes if available, or separate codes for the infection and the organism if not.
📌 Zika virus infection coding requires a confirmed diagnosis, with a statement from the physician being sufficient, and suspected or possible cases are coded differently.

Q & A

What is the focus of Chapter 1 in the ICD-10-CM coding guidelines?
-Chapter 1 focuses on certain infectious and parasitic diseases, which include codes A00 through B99.
How is coding for Human Immunodeficiency Virus (HIV) infections handled in the guidelines?
-Coding for HIV infections is based on confirmed cases, with clinical judgment and diagnostic statement being sufficient for code assignment, not requiring positive serology or culture documentation.
What are the five key codes to remember when dealing with HIV coding?
-The five key codes to remember are B20, Z21, R75, Z11.4, and Z11.7.
How should a patient admitted for an HIV-related condition be coded?
-The first listed code should be B20, followed by the specific HIV-related condition the patient has.
What is the correct sequence for coding a patient admitted for an unrelated condition but is HIV positive?
-The sequence should start with the code for the unrelated condition, followed by the HIV disease code B20, and then any other HIV-related conditions affecting treatment.
How is asymptomatic HIV coded in the ICD-10-CM?
-Asymptomatic HIV is coded as Z21, which is used without any documentation of symptoms related to HIV.
What is the significance of the code R75 in the context of HIV testing?
-Code R75 is used for inconclusive HIV tests, where there is no definitive diagnosis or manifestations of HIV-related illness.
How should sepsis be coded when the underlying infection or organism is not specified?
-In such cases, the default code A41.9 for sepsis due to unspecified organism should be used.
What is the correct approach when a patient presents with severe sepsis?
-Severe sepsis requires two codes: one for the underlying systemic infection and another from the category A55.2 for severe sepsis with acute organ dysfunction.
How is MRSA colonization coded in the ICD-10-CM?
-MRSA colonization is coded using Z22.33 for a carrier or suspected carrier of MRSA, and Z22.31 for a patient with susceptible Staphylococcus aureus.
What is the Zika virus coding in the ICD-10-CM when only a possible or probable diagnosis is documented?
-When the provider documents a possible or probable Zika virus infection, the code Z20.81 for contact with and suspected exposure to Zika virus should be used instead of the confirmed Zika code A92.5.

Outlines

00:00

📚 Introduction to ICD-10-CM Coding Guidelines: Infectious and Parasitic Diseases

This paragraph introduces the video series focusing on ICD-10-CM coding guidelines, specifically Chapter 1 which covers certain infectious and parasitic diseases (codes A00 through B99). The discussion begins with guidelines for coding human immunodeficiency virus (HIV) infections, emphasizing the importance of coding confirmed cases as per guidelines. It highlights that clinical judgment can be used to assign a code for HIV, even without positive serology or culture. The video also mentions five key codes (B20Z, 21, 75Z, 11.4, and Z11.7) to be considered when exploring HIV coding rules.

05:00

🌟 HIV Coding and Sequencing

This section delves into the specifics of HIV coding, including the sequencing of cases where patients are admitted for HIV-related conditions. It advises that the first listed code should be B20, followed by the specific HIV-related condition. The video also addresses scenarios where patients are admitted for unrelated conditions, emphasizing the sequencing of the unrelated condition code first, followed by the HIV code (B20). Additionally, it discusses the irrelevance of the date of HIV diagnosis to sequencing decisions and the coding of asymptomatic HIV as Z21.

10:06

🔬 Inconclusive Tests and Previously Diagnosed HIV

This paragraph discusses the coding of inconclusive HIV tests using the code R75, which requires no definitive diagnosis or manifestations of HIV-related illness. It also covers the coding for previously diagnosed HIV, stressing that once a patient is coded as B20, they should not be assigned codes I75 and Z21交替. The video then moves on to discuss HIV and pregnancy, emphasizing that pregnancy codes (category O98.7) take priority over other codes. Finally, it covers HIV testing encounters, using codes Z11.4 for testing and Z71.7 for counseling, with additional codes for high-risk behaviors and signs/symptoms if applicable.

15:09

🦠 Coding Infectious Agents and Antibiotic Resistance

This section addresses the coding of infectious agents as the cause of disease, highlighting the use of secondary codes to specify the exact organism involved. It mentions the categories B95, B96, and B97 for such coding. The video also discusses the coding of antibiotic-resistant infections, requiring the assignment of a code from the Z16 category following the infection code. The segment concludes with an exploration of severe sepsis and septic shock, emphasizing the complexity of coding these conditions and the need for collaboration with clinicians for accurate documentation and code assignment.

20:11

🏥 Sepsis and Septic Shock Coding

This paragraph provides detailed guidelines for coding sepsis and septic shock, including the assignment of codes for underlying systemic infections and additional codes for acute organ dysfunction (AOD). It clarifies that a code for severe sepsis (65.2) should only be used when AOD is documented and associated with sepsis. The video also discusses the coding of negative or inconclusive blood cultures in sepsis cases, emphasizing that a physician's clinical judgment can still determine sepsis. It addresses the nonspecific term 'urosepsis' and its inapplicability in ICD-10-CM coding, as well as the coding of septic shock, which involves circulatory failure associated with severe sepsis.

25:12

🦠 MRSA and Zika Virus Coding

The final paragraph focuses on the coding of MRSA (methicillin-resistant Staphylococcus aureus) infections and Zika virus infections. It explains the use of combination codes for MRSA infections and the assignment of additional codes for the organism when no combination code exists. The video also covers the coding of MRSA colonization (Z22.3) and the infection (B95.62). Lastly, it addresses the coding of confirmed Zika virus infections (A92.5) and the use of Z20.8 for suspected exposure to Zika virus.

Mindmap

Keywords

💡ICD-10-CM

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is a system used in the United States for coding diagnoses and procedures associated with hospital and outpatient care. In the video, it is the framework within which the speaker discusses coding guidelines for infectious and parasitic diseases, emphasizing the importance of accurate coding as per the ICD-10-CM guidelines.

💡HIV

Human Immunodeficiency Virus (HIV) is a virus that attacks the immune system and can lead to Acquired Immunodeficiency Syndrome (AIDS). In the context of the video, the speaker provides detailed guidelines for coding HIV infections, including the importance of confirming cases and the use of specific codes like B20 and Z21.

💡Coding

Coding in the medical context refers to the process of assigning standardized codes to diagnoses, procedures, and other health information. The video emphasizes the importance of following specific coding guidelines for infectious diseases, such as HIV and sepsis, to ensure accurate documentation and reimbursement.

💡Sepsis

Sepsis is a life-threatening condition caused by the body's response to an infection. It is characterized by the body's inflammatory response to an infection that can lead to tissue damage, organ failure, and even death if not treated promptly. The video discusses the complexity of coding sepsis, including the distinction between sepsis and severe sepsis, and the need for collaboration with clinicians for accurate coding.

💡MRSA

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that is resistant to many antibiotics, making it difficult to treat. In the video, the speaker discusses the coding of MRSA infections, including the use of combination codes and the distinction between MRSA infection and colonization.

💡Zika Virus

The Zika virus is a mosquito-borne virus that can cause fever, rash, joint pain, and conjunctivitis, and is known for its potential to cause severe birth defects when pregnant women are infected. The video provides specific guidelines for coding Zika virus infections, emphasizing that only confirmed cases should be coded and that the diagnosis does not require documentation of the test type.

💡Confirmation of Diagnosis

In medical coding, confirmation of diagnosis refers to the verification that a patient indeed has the condition being coded. The video highlights that for certain conditions like HIV, confirmation is necessary but does not strictly require positive serology or culture results; a provider's clinical judgment can suffice.

💡Sequencing of Codes

Sequencing of codes in medical coding is the process of arranging the codes for diagnoses and procedures in a specific order according to established guidelines. This order can affect the interpretation of the medical record and the reimbursement for healthcare services. The video provides detailed instructions on how to sequence codes for conditions like HIV and sepsis.

💡Asymptomatic HIV

Asymptomatic HIV refers to the stage of HIV infection where the virus is present in the body, but the individual does not exhibit symptoms of the disease. The video emphasizes the coding of asymptomatic HIV using a specific code (Z21) and clarifies that this code should be used without any documentation of HIV-related symptoms.

💡Inconclusive Tests

Inconclusive tests in the medical context refer to laboratory results that do not provide a definitive answer about a patient's condition. The video discusses how to code in situations where a patient has an inconclusive test for HIV, using a specific code (R75) when there is no definitive diagnosis or manifestations of HIV-related illness.

💡Severe Sepsis

Severe sepsis is a critical care condition that occurs when sepsis leads to acute organ dysfunction or failure. The video outlines the coding guidelines for severe sepsis, which require the assignment of two codes: one for the underlying systemic infection and another for the severe sepsis itself, using the code from the 65.2 category.

Highlights

The video series focuses on ICD-10-CM coding guidelines, specifically chapter 1 which covers certain infectious and parasitic diseases.

Coding for Human Immunodeficiency Virus (HIV) infections is primarily based on confirmed cases, with clinical judgment being sufficient for diagnosis.

Five key codes to remember for HIV coding are B20, Z21, R75, 111.4, and 111.7.

For patients admitted for HIV-related conditions, the first listed code should be B20, followed by the specific HIV-related condition.

In cases where HIV-positive patients are admitted for unrelated conditions, the unrelated condition code is listed first, followed by the HIV code B20.

The date of HIV diagnosis is irrelevant to sequencing decisions.

Asymptomatic HIV is coded to Z21, used without documentation of any symptoms related to HIV.

Inconclusive HIV tests are coded using R75, which requires no definitive diagnosis or manifestations of HIV-related illness.

For previously diagnosed HIV patients, B20 is used on every encounter, and other codes like R75 and Z21 are not assigned together with B20.

Pregnancy codes from chapter 5 have sequencing priority over HIV-related codes.

For HIV testing, Z11.4 is used, and additional codes may be assigned to show high-risk behavior or counseling provided.

Infections caused by MRSA (methicillin-resistant Staphylococcus aureus) are coded using combination codes that include both the infection and the organism.

MRSA colonization or carriage is coded differently from an active MRSA infection.

For Zika virus infection, a confirmed diagnosis is required for coding, and the physician's statement is sufficient for confirmation.

Sepsis and severe sepsis require collaboration with clinicians for accurate documentation and code assignment.

Severe sepsis is coded with two codes: the underlying systemic infection and a code from the 65.2 category for acute organ dysfunction.

Septic shock is generally coded with the systemic infection code first, followed by a code for acute organ dysfunction (65.21 or T81.12).

The guidelines emphasize the importance of understanding the relationship between infections, procedures, and sepsis for accurate coding.

Transcripts

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Related Tags

ICD-10-CM Infectious Diseases Coding Guidelines HIV Coding Sepsis Treatment MRSA Management Medical Documentation Healthcare Professionals Coding Education Clinical Judgment