HIV (Human Immunodeficiency Virus) Infections
- For AIDS/HIV related illness, Use B20.
- If a patient is admitted for any HIV related condition – Code HIV (B20)as primary Dx followed by HIV related conditions.
- If an HIV positive patient is admitted for unrelated condition eg, Injury.
- Code unrelated condition as primary Dx followed by B20
- Asymptomatic HIV – Use Z21, for a known HIV or HIV positive patient or HIV test is positive patient without any associated symptoms.
Note: Don’t use Z21 for AIDS or patient treated for HIV related illness (B20)
- For Inconclusive laboratory evidence of HIV – Use R75
- If a Pregnant patient admitted with HIV related condition, Use O98.7-(HIV disease complicating pregnancy, childbirth and the puerperium) as the primary diagnosis, followed by B20 & code for HIV related condition.
Note: For Asymptomatic patient use Z21 as the secondary code.
- Encounter for screening for HIV – Use Z11.4
- HIV test results are negative – Use Z71.7(HIV Counseling).
Sepsis, Severe Sepsis and Septic Shock
- SEPSIS: If the type of infection or causal organism is not specified, assign code A41.9 (Sepsis, unspecified organism).
- SEVERE SEPSIS (If sepsis associated with acute organ dysfunction), requires a minimum of two codes.
How to code severe sepsis,
- A code for underlying systemic infection should be coded first, {If the causal organism is not documented, use A41.9 (Sepsis, Unspecified organism)}
- Followed by a code from subcategory R65.20 (Severe sepsis)
- Additional codes for associated acute organ dysfunction.
Note: If the acute organ dysfunction is not related to the sepsis, don’t code R65.2- (Severe sepsis)
- SEPTIC SHOCK: Circulatory failure (acute organ dysfunction) associated with severe sepsis.
How to code septic shock,
- A code for underlying systemic infection should be coded first, {If the causal organism is not documented, use A41.9 (Sepsis, Unspecified organism)}
- Followed by a code R65.21 (Severe sepsis with septic shock)
- Additional codes for associated other acute organ dysfunction.
- Sepsis due to a post-procedural infection:
T80.2 – Infections following infusion, transfusion, and therapeutic injection,
T81.4 – Infection following a procedure,
T88.0 – Infection following immunization,
O86.0 – Infection of the 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 and the additional code(s) for any acute organ dysfunction.
- Post-procedural infection and postprocedural septic shock
When a post-procedural infection has occurred and resulted in severe sepsis and postprocedural septic shock,
T81.4, Infection following a procedure, (or)
O86.0, Infection of obstetrical surgical wound
Should be coded first
Followed by code R65.21 (Severe sepsis with septic shock) &
Code for the systemic infection.
- Sepsis and severe sepsis associated with a noninfectious process
Some cases a noninfectious process like trauma may lead to an infection which can result in sepsis or severe sepsis.
If the noninfectious process meets the definition of principal diagnosis, then the noninfectious conditions should be sequenced first followed by a code for the resulting infection.
If severe sepsis is present, a code from category R65.2- should also be assigned along with any associated acute organ dysfunction codes.
Methicillin-Resistant Staphylococcus aureus (MRSA) Conditions
- Combination codes for MRSA infection.
When a patient is diagnosed with an infection that is due to MRSA and that infection has a combination code that includes the causal organism, assign the appropriate combination code for the condition
Eg: A41.02 (Sepsis due to MRSA)
J15.212 (pneumonia due to MRSA)
- No combination codes for MRSA infection
When a patient is diagnosed with an infection that is due to MRSA and that infection doesn’t have a combination code includes the causal organism, assign the appropriate code for that condition along with code B95.62 (MRSA infection as the cause of diseases classified elsewhere) for the MRSA infection.
Methicillin-susceptible Staphylococcus aureus (MSSA) and MRSA colonization
- Colonization means that MSSA or MSRA is present on or in the body without necessarily causing illness.
Z22.322, Carrier or suspected carrier of Methicillin-resistant Staphylococcus aureus, for patients documented as having MRSA colonization.
Z22.321, Carrier or suspected carrier of Methicillin-susceptible Staphylococcus aureus, for patient documented as having MSSA colonization.
MRSA colonization and infection
If a patient is documented as having both MRSA colonization and infection during a hospital admission,
Assign Z22.322 (Carrier or suspected carrier of Methicillin-resistant Staphylococcus aureus) and a code for the MRSA infection.
