Chapter 1: Infectious & Parasitic Diseases (A00–B99), COVID-19 & Post-COVID Flashcards
(59 cards)
When can you assign an HIV diagnosis code?
Only when the case is confirmed—either by provider documentation or diagnosis of an HIV-related illness.
How do you code a patient admitted for an HIV-related illness?
Use B20 as the principal diagnosis, then add all related conditions.
Exception: If the patient has hemolytic-uremic syndrome, code D59.31 first, then B20.
How do you code a patient with HIV admitted for an unrelated condition?
Code the unrelated condition first, then B20 and any related HIV conditions.
Does the timing of the HIV diagnosis affect coding?
No, sequence codes based on the reason for the visit, not when HIV was diagnosed.
When do you use Z21 for HIV?
Use Z21 for asymptomatic HIV only. If the patient has AIDS or any related illness, use B20.
How do you code an inconclusive HIV test?
Use R75.
If a patient previously had an HIV-related illness, what code do you always use moving forward?
B20 — even if the illness resolved.
How do you code HIV during pregnancy, childbirth, or postpartum?
Use O98.7- first, then B20 or Z21 based on symptoms.
What code is used for HIV screening?
Z11.4. Add Z71.7 if counseling is provided.
What if the HIV test is positive?
Follow regular HIV coding guidelines (e.g., B20 or Z21).
What if the patient is on antiretrovirals?
Use B20 and Z79.899 (for antiretroviral use).
What code is used for HIV PrEP?
Z29.81 plus any risk factor codes.
Is “urosepsis” a valid diagnosis for coding?
No. You must ask the provider to clarify if it’s sepsis or just a UTI.
When can you assign a severe sepsis code (R65.2)?
Only if there’s sepsis with documented organ dysfunction and they’re linked.
If organ dysfunction is present but unrelated to sepsis, do you use R65.2?
No. Only use R65.2 if the organ failure is due to sepsis.
How do you code severe sepsis?
Code the infection first, then R65.2, and then codes for organ dysfunction.
How do you code septic shock?
Code the sepsis first, then R65.21 or T81.12 (if post-surgical), and also include any organ dysfunctions.
Can you ever code septic shock as the principal diagnosis?
No. It is never coded first.
If a patient has both sepsis and another serious condition, which goes first?
Whichever one caused the admission; if unclear, use Section II, C guidance.
How do you code a patient admitted for both sepsis and pneumonia?
Sepsis code first, then pneumonia, then R65.2 if there’s severe sepsis.
If a patient is admitted for pneumonia but develops sepsis later, how do you code it?
Code pneumonia first, then sepsis/severe sepsis codes.
True or False: You can code postprocedural sepsis without provider documentation.
False. Documentation must say the infection was due to the procedure.
How do you code post-surgical sepsis?
First: surgical infection code (T81.4- or O86.0-)
Then: T81.44 or O86.04 (procedure-related sepsis)
Then: organism + R65.2 if needed
What code do you use for postprocedural septic shock?
T81.12
