Chapter 1 coding guidelines

How to code for only confirmed cases of HIV

The providers documentation is enough to without testing:

1. Code B20

*Once B20, always B20

• Once Assigned, the coder MAY NEVER USE ANY OTHER HIV-related code for this patient

Coding for admission for HIV-Related Conditions

1. Sequence B20 FIRST!

   • Sequence B20 first, then HIV-Related Conditions are coded second.

2. B20 is Always Coded with HRC

   • HIV related conditions is HIV with symptoms and is NEVER asymptomatic

3. Use B20

   • Use B20 even when HIV is not documented

How to code when an encounter is NOT RElATED to HIV

1. Code the REF

   • Sequence the reason for the encounter FIRST!

2. B20 or Z21

   • Type of HIV Second

3. HIV-RELATED CONDITIONS

   • If the patient has any HIV related conditions

How to code for HIV in Pregnancy, Childbirth, Puerperium

1. Sequence O code First

   • Sequence the 098.7-1st when there are complications in pregnancy

2. Type of HIV?

   • B20 or Z21

3. HIV RELATD-Illness

• Check the HIV Indicators in the ICD-10-CM manual

How to code for an Encounter for HIV Testing/Screening

1. Z11.4

   • Sequence the encounter for HIV screening

2. High Risk Behaviors

   • High Risk Behaviors are sequenced second

3. If confirmed HIV positive

   • Use the HIV positive code B20 or Z21 and disregard 1&2

How to code Sepsis

1. Code first

   • The systemic infection or causal organism

2. No specific code available?

   • Use A41.9

3. DO NOT Use R65.2-

   • Unless there is an organ dysfunction

How to code Sepsis with an Organ Dysfunction (severe sepsis)

1. Code first

   • the systemic infection or causal organism

2. No specific code available?

   • Use A41.9

3. DO NOT Use R65.2-

   • Unless there is an organ dysfunction

Sepsis with organ dysfunction (severe sepsis)

1. Code first

   • The underlying systemic infection or/A41.9

2. Code second

   • R65.20 for Sever Sepsis (this code may NEVER be sequenced first)

3. Code third

   • Code the Associated Organ dysfunction

Sepsis + associated organ dysfunction = sever sepsis

When there is no avalible MRSA Combination Code

1. First Code

   • the causal organism, infection, condition

2. Code second

• B95.62

3. Do Not Use

4. Z16.11 with MRSA codes

MRSA/MSSA Colonization

1.Code first

• Z22.322 (Carrier or suspected carrier of Methicillin-resitant Staphylococcus aureus)

2. Code first MSSA

   • Z22.321 (Carrier or suspected carrier of Methicillin susceptible Staphylococcus aureus)

3. Check the documentation

   • For accurate code selection

MRSA Carrier and Suspected Carrier with Infection

1. Code First

   • Specific MRSA combination code or local infection

2. Code second

   • If not specific Combo MRSA code, code B96.62

3. Code the carrier code

   • Z22.322 (Carrier or suspected carrier of Methicillin-resitant Staphylococcus aureus)

Zika Virus

Only code confirmed cases

1. confirmed diagnosis A92.5

2. S/S (Signs and Symptoms) or Z20.821

• Do not code A92.5 without a confirmed diagnosis

• Code only for confirmed cases documented by the provider

Code only confirmed cases of Covid 19

1. Confirmed cases: Use U07.1 for confirmed cases only

   • A positive test result is not required if the provider documents a COVID-19 diagnosis.

2. DO NOT: Use U07.1 for unconfirmed cases and do not code signs/symptoms of COVID-19 when positive

   • Unconfirmed (suspected, possible, probable, or inconclusive): assign codes for signs or symptoms

3. Provider’s Documentation: Is sufficient and serology/antigen test is not required when the Dr. has documented COVID-19 positive

4. Presumptive tests: Are classified as confirmed

When COVID-19 Meets Definition of First-Listed

1. Code First: U07.1 (COVID 19)

2. Code second: manifestations of COVID 19 (e.g, pneumonia, bronchitis, ect.)

3. Exceptions:

   • Sepsis/Severe Sepsis/Septic Shock: Sequence per sepsis guidelines

   • Pregnancy, childbirth, puerperium: Use 098.5- first

   • Newborns: Use neonatal guidelines

   • Lung Transplant Patient: Follow transplant complication guidelines

Post COVID-19 Conditions (Sequela)

1. First code: Resulting condition (sequela)

2. Second code: U09.9

3. Carefully read the documentation:

   • Look for keywords: Sequela, Post Covid-19 (if the doctor documents the NEW condition as due to COVID-19, then it is a sequela of COVID-19) and after COVID-19 has resolved