ICD-10-CM Guidelines 2023 C. Chapter-Specific

Question 1

C.1.a - HIV

HIV

Answer 1

• 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.

Question 2

Asymptomatic HIV

Answer 2

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

Question 3

Inconclusive HIV serology

Answer 3

Inconclusive HIV serology without a definitive diagnosis or manifestations, assign R75: inconclusive laboratory evidence of HIV

Question 3

Previously diagnosed HIV-related conditions

Answer 3

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

Question 3

HIV in Pregnancy, Childbirth and the Puerperium

Answer 3

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

Question 3

Encounter for follow-up of HIV test results

Answer 3

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

Question 4

HIV managed by antiretroviral medication

Answer 4

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

Question 4

Encounter for HIV testing

Answer 4

*Encounters for testing HIV status - Z11.4, Encounter for screening for HIV
*Use additional codes for any high-risk behavior, if applicable

Question 4

Encounter for HIV testing with sign/symptoms

Answer 4

Code first the signs/symptoms;
An additional code Z71.7, HIV counseling may be assigned if counseling is provided during the encounter

Question 5

Infectious Agents

Answer 5

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

Question 6

Infections resistant to antibiotics

Answer 6

Assign Z16, resistance to antimicrobial drugs, following the infection code only if the infection code does not include the drug resistance

Question 7

Sepsis

Answer 7

Assign the code for the underlying infection; if the infection or causal organism isn’t specified, assign A41.9, sepsis, unspecified organism

Question 8

Sepsis - negative or inconclusive blood culture

Answer 8

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

Question 8

Urosepsis

Answer 8

A nonspecific term; NOT considered synonymous with sepsis.
*has NO DEFAULT code
*If documented, the provider MUST be queried for clarification

Question 8

Severe sepsis

Answer 8

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

Question 8

Acute organ dysfunction not clearly associated with sepsis

Answer 8

If an acute organ dysfunction is not clearly associated with sepsis or the documentation indicates the cause as a condition other than sepsis, DO NOT assign R65.2, severe sepsis.
*If unclear, query the provider

Question 8

Sepsis with organ dysfunction

Answer 8

Sepsis and associated acute organ dysfunction or multiple organ dysfunctions should be assigned severe sepsis, R65.2
*Severe sepsis should not be assigned UNLESS documentation supports “severe sepsis” or and associated acute organ dysfunction