Infectious and Parasitic Diseases

Appendix C – contains information to help with diseases in these chaptersMultiple coding often necessary

Identify:Body SiteSeverity of the diseaseSpecific organismEtiology of infectionAssociated signs, symptoms, manifestation

Infectious diseasesExamples: TB, HIV, Septicemia

Late Effects: identifies the underlying cause of a condition currently present in the patientExample: Mental retardation due to old

viral encephalitis319 Unspecified Mental

retardation139.0 Late effects of viral

encephalitis

HIV Classification

Code only confirmed cases of HIV infection/illness; records with statements of “suspected”, “likely”, “possible”, or “questionable” are to be returned to the physician for clarification

Codes: 042, V08, and 795.71 are used together to code positive HIV diagnoses.

NeoplasmsNeoplasm behavior:

MalignantPrimarySecondaryIn SituBenignUncertain behaviorUnspecified nature

Morphology codes (M)Explain the histology and behavior

of a neoplasmFour digits with a fifth separated

by a forward slash (M8140/3)The fifth digit is the behavior code

/0 benign /1 uncertain/borderline

/2 in situ/ intraepithelial/noninvasive/noninfiltrating

/3 malignant/primary /6 malignant -2ndary or metastatic/9 malignant, uncertain if primary or

metastatic

V CodesRecords chemotherapy, radiation

therapy, follow-up visits, family history of cancer, history of primary malignancy

Designates the malignancy as the principal diagnosis, EXCEPT: when the admission or encounter is SOLELY for administration of chemotherapy, immunotherapy, or radiation therapy

When exception: V code is principal diagnosis code, malignancy is additional diagnosis

Coding NeoplasmsBy systemBy site (anatomical, Primary)Type (previous slide)Asterisk – when it follows the

term of location, that code cannot be used, must be more specific

Metastatic from – primary is the site the new growth is ‘from’

Metabolic/Immunity Disorders

Diabetes: with or without meds, types, lead to other illnesses

Gout: acute, chronic, with other illnesses

Imbalances: Too much or not enough fluid, acid levels, etc.

Blood/Organs

Anemia: Types, side effects, cause

Clotting: Where, cause, complications, due to

White blood cells: Diseases, usually need 4th and 5th digits

Blood forming organs: Tissue damage, organ shut down or transplant

Mental DisordersSections:

Psychoses

Neurotic Disorders, Personality Disorders,other Nonpsychotic mental disorders

Mental Retardation

Fifth digits occur frequently in mental disorder diagnoses

Categories:Axis I: All psychiatric except personality

and mental retardationAxis II: Personality disorders and mental

retardationAxis III: IDs the presence of general

medical conditionsAxis IV: Note clinically relevant

psychosocial and environmental problemsAxis V: Indicates the individual’s overall

psychological, social and occupational functioning

Axes I, II, and III provide diagnostic information

Alcohol and DrugsAlcoholism: chronic mental

condition coded under Alcohol dependence syndrome – several forms

Drug dependence: chronic mental and physical condition coded under drug addiction – several stages

Fifth digits for alcohol/drug dependence and abuse:• 0 Unspecified 1 Continuous• 2 Episodic 3 Remission

Therapy for DependenceDetoxificationRehabilitationCoding therapies:• Tabular List• 94.61 Alcohol rehabilitation (94.64

drug re)• 94.62 Alcohol detoxification (94.65

drug de)• 94.63 Alcohol rehab and detox

(94.66 drug)• There are codes for combinations of

alcohol and drug dependence