ICD-10-CM Guidelines 2023 C. Chapter-Specific Flashcards
C.1.a - HIV
HIV
- Code only confirmed cases
- Admission for an HIV-related condition, the PDx is B20 followed by the HIV-related condition.
*Exception - if admission due to hemolytic-uremic syndrome associated with HIV disease, D59.31 is PDx followed by B20, HIV disease.
Asymptomatic HIV
Z21 - documented as “HIV positive”, “known HIV” or similar terminology.
*DO NOT use Z21 with “AIDS” or “HIV disease”, or HIV-related condition, use B20 instead
Inconclusive HIV serology
Inconclusive HIV serology without a definitive diagnosis or manifestations, assign R75: inconclusive laboratory evidence of HIV
Previously diagnosed HIV-related conditions
Once the patient has a prior history of HIV-related illness, assign B20.
*B20 should be assigned on every subsequent admission/encounter.
*DO NOT use R75 or Z21
HIV in Pregnancy, Childbirth and the Puerperium
If admitted for an HIV-related illness, assign O98.7-, HIV complicating pregnancy, childbirth and the puerperium followed by B20 and the code(s) for the HIV-related illness(es).
*Codes from Ch.15 take precedence in sequencing
Encounter for follow-up of HIV test results
Use Z71.7 HIV counseling for the PDx; if results are positive assign B20 (HIV test positive, or similar terminology); inconclusive - assign R75.
If negative, assign Z71.7 counseling
HIV managed by antiretroviral medication
If a patient with documented HIV, HIV-related illness or AIDS is currently being managed on antiretroviral meds, assign B20; Z79.899 for long term/current use of antiretroviral meds can be assigned
Encounter for HIV testing
*Encounters for testing HIV status - Z11.4, Encounter for screening for HIV
*Use additional codes for any high-risk behavior, if applicable
Encounter for HIV testing with sign/symptoms
Code first the signs/symptoms;
An additional code Z71.7, HIV counseling may be assigned if counseling is provided during the encounter
Infectious Agents
For infections classified in chapters other than Ch.1 use additional code from Ch.1 to identify the organism
Ex: B95, Strep, staph and enterococcus as the cause of diseases classifi
Infections resistant to antibiotics
Assign Z16, resistance to antimicrobial drugs, following the infection code only if the infection code does not include the drug resistance
Sepsis
Assign the code for the underlying infection; if the infection or causal organism isn’t specified, assign A41.9, sepsis, unspecified organism
Sepsis - negative or inconclusive blood culture
Negative or inconclusive blood cultures do not preclude a dx of sepsis in patients with clinical evidence of the condition; the provider should be queried
Urosepsis
A nonspecific term; NOT considered synonymous with sepsis.
*has NO DEFAULT code
*If documented, the provider MUST be queried for clarification
Severe sepsis
Requires two codes: Code first the underlying systemic infection followed by R65.2, severe sepsis.
*If the causal organism is not specified, assign A41.9 for the infection.
*Assign additional codes for the associated acute organ dysfunction