Chapter 4 Flashcards Preview

MRT 132 > Chapter 4 > Flashcards

Flashcards in Chapter 4 Deck (32):
1

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

2

Sepsis does not

occur without a reason

3

What causes sepsis?

Bacterial infections are most common

4

Rapid breathing, change in mental status, fever, chills, decreased urination, rapid plus and breathing, nausea and vomiting,

Symptoms of sepsis

5

mottled skin, difficulty breathing, abnormal heart function, sign, decreased union

severe sepsis symptoms

6

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

7

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

8

If unknown type of sepsis, code

A41.9 Sepsis, unspecified

9

Coding Severe sepsis

requires a minimum of two codes.
1. A code
2. R65.2

10

R65.2

(only when dx of severe sepsis or associated acute organ dysfunction has been doc)

11

Pt admitted with both (severe) sepsis and a localized infection (cellulitis)

1. Systemic infection
2. localized infection

12

If (severe) sepsis doesn't occur until after the admission for a localized infection

1. localized infection
2. (severe) sepsis

13

SIRS

severe sepsis

14

Human immunodeficiency virus (HIV) disease (AIDS ARC)

B20

15

Asymptomatic human immunodeficiency virus (HIV) infection status

Z21
-NO HIV-realted illness

16

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

17

HIV- Related Illness

-minimus of two codes
1. B20 -identify the HIV disease
2. manifestations

18

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

19

Asymtomatic HIV Infection Status

Z21- PT has HIV but no documentation of symptoms of the infection
-NO HIV-related illnesses

20

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

21

Encounter for testing HIV

High rise behaviors

Counseling HIV

Positive HIV test

Z11.4

Z72.5-

Z71.7

Z21

22

infections documented as drug resistant

Codes in Z16

23

Finding infections in index

Resistance, resistant
-organism, to, drug

24

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

25

Zika Virus

Code only confirmed cases
A92.5

26

Severe sepsis with extremely low blood pressure (hypotension), not responsive to fluids. Represents circulatory failure

Septic Shock

27

SIRS (body’s immune response to infection) and an infection. This represents a systemic infection

Sepsis

28

Sepsis with acute organ dysfunction/failure

Severe Sepsis

29

Symptomatic HIV, HIV related illness, AIDS, AIDS related complex

B20

30

Asymptomatic HIV, no history of HIV related illness

Z21

31

Inconclusive laboratory evidence of HIV, Nonconclusive HIV test finding.

R75

32

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