Chapter 4 Flashcards
Sepsis
- caused by the body’s immune response to an infection
- Immune system releases chemicals into the blood to fight the infection and triggers widespread inflammation
Sepsis does not
occur without a reason
What causes sepsis?
Bacterial infections are most common
Rapid breathing, change in mental status, fever, chills, decreased urination, rapid plus and breathing, nausea and vomiting,
Symptoms of sepsis
mottled skin, difficulty breathing, abnormal heart function, sign, decreased union
severe sepsis symptoms
Severe sepsis
(systemic inflammatory response syndrome (SIRS))
- Severe sepsis is an infection with associated acute organ dysfunction
- One or more of the body organs will fail
Septic Shock
- occurs in extreme cases when the patient develops very low blood pressure and heart failure
- Causes circulatory failure
- Causes failure of the lungs, kidneys, and liver
If unknown type of sepsis, code
A41.9 Sepsis, unspecified
Coding Severe sepsis
requires a minimum of two codes.
- A code
- R65.2
R65.2
(only when dx of severe sepsis or associated acute organ dysfunction has been doc)
Pt admitted with both (severe) sepsis and a localized infection (cellulitis)
- Systemic infection
2. localized infection
If (severe) sepsis doesn’t occur until after the admission for a localized infection
- localized infection
2. (severe) sepsis
SIRS
severe sepsis
Human immunodeficiency virus (HIV) disease (AIDS ARC)
B20
Asymptomatic human immunodeficiency virus (HIV) infection status
Z21
-NO HIV-realted illness
Coding HIV
- Only confirmed cases of HIV infection or illness are coded
- Suspected, possible or other terms that reflect uncertainty are not coded per guidelines
HIV- Related Illness
- minimus of two codes
1. B20 -identify the HIV disease
2. manifestations
When a patient with HIV disease is admitted for an unrelated condition, such as a traumatic injury or a disease that was not caused by the HIV disease
code first the unrelated condition
Asymtomatic HIV Infection Status
Z21- PT has HIV but no documentation of symptoms of the infection
-NO HIV-related illnesses
Patient known with prior diagnosis of HIV-realted illness
code with B20 (no more use of Z21)
-once B20 use, always use it in every subsequent visit or admission
Encounter for testing HIV
High rise behaviors
Counseling HIV
Positive HIV test
Z11.4
Z72.5-
Z71.7
Z21
infections documented as drug resistant
Codes in Z16
Finding infections in index
Resistance, resistant
-organism, to, drug
MRSA
– Combination code that identifies the infection is due to MRSA
• A41.01, Sepsis due to MRSA
– Using an additional code to identify the MRSA as the causative organism with a code for the site of the infection
• I33.0, Acute or subacute infective endocarditis
• B95.62, Methicillin-resistant Staphlococcus aureus infection as cause of disease classified elsewhere
Zika Virus
Code only confirmed cases
A92.5
Severe sepsis with extremely low blood pressure (hypotension), not responsive to fluids. Represents circulatory failure
Septic Shock
SIRS (body’s immune response to infection) and an infection. This represents a systemic infection
Sepsis
Sepsis with acute organ dysfunction/failure
Severe Sepsis
Symptomatic HIV, HIV related illness, AIDS, AIDS related complex
B20
Asymptomatic HIV, no history of HIV related illness
Z21
Inconclusive laboratory evidence of HIV, Nonconclusive HIV test finding.
R75
If a patient was admitted 6 months ago with an HIV related illness and now presents for an acute asthma exacerbation, what code will be assigned for the HIV by the coder when it is reported as an additional diagnosis?
B20
