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| 4291814555 | Chapter 1 - certain infectious and parasitic diseases | A00 - B99 | 0 | |
| 4291814556 | Human immunodeficiency virus - HIV infections | 1. Code only confirmed cases *NOTE:* hospital inpatient guideline section II, H is an exception | 1 | |
| 4291814557 | Hospital inpatient guideline section II, H: | Confirmation does not require documentation of positive serology or culture for HIV The provider's diagnostic statement that the patient is HIV positive is sufficient The providers diagnostic statement that the patient has an HIV related illness is sufficient | 2 | |
| 4292129686 | Selection and sequencing of HIV codes / patient admitted for hiv-related condition | If a patient is admitted for an hiv-related condition - 1. Principal diagnosis should be B20: (HIV) disease 2. Additional diagnosis codes follow for all reported hiv-related conditions | 3 | |
| 4292129687 | Selection and sequencing of HIV codes / patient with HIV disease admitted for unrelated condition | If a patient with (HIV) disease is admitted for an unrelated condition - 1. The unrelated condition code should be the Principal diagnosis 2. Secondary diagnosis would be B20: (HIV) disease 3. Additional diagnosis codes for all reported hiv-related conditions would follow | 4 | |
| 4292129688 | Selection and sequencing of HIV codes / whether the patient is newly diagnosed | Whether or not the patient is newly diagnosed or has previous admissions / encounters for HIV conditions is irrelevant to the sequencing decision | 5 | |
| 4292129689 | Selection and sequencing of HIV codes / asymptomatic human immunodeficiency virus | When a patient without any documentation of symptoms is listed as being "hiv-positive", "known HIV", "HIV test positive", or similar terminology - 1. Code Z21: asymptomatic human immunodeficiency virus infection | 6 | |
| 4292129690 | Selection and sequencing of HIV codes / the term AIDS is used | Do not use code Z21 - 1. If the term AIDS is used 2. If the patient is treated for any hiv-related illness 3. If the patient is described as having any conditions resulting from HIV positive status ...In these cases code B20: HIV disease | 7 | |
| 4292129691 | Selection and sequencing of HIV codes / patients with inclusive HIV serology | Code R75: inclusive laboratory evidence of human immunodeficiency virus (HIV) 1. For patients with inclusive HIV serology, but no definitive diagnosis or manifestations of the illness | 8 | |
| 4292129692 | Selection and sequencing of HIV codes / previously diagnosed HIV related illness | Code B20: (HIV) disease - 1. Patients with any known prior diagnosis of an hiv-related illnesses *Note:* once a patient has developed an HIV related illness, the patient should always be assigned code B20 on every subsequent encounter | 9 | |
| 4292129693 | puerperium (pyu-er-pir-ee-em) | The period between childbirth and the return of the uterus to its normal size | 10 | |
| 4292129694 | Selection and sequencing of HIV codes / HIV infection in pregnancy, childbirth and the puerperium | During pregnancy comma childbirth or the puerperium, a patient admitted because of an HIV related illness should receive a principal diagnosis code - 1. Code O98.7: human immunodeficiency disease (HIV) complicating pregnancy, childbirth and the puerperium 2. Followed by B20 HIV disease 3. Followed by any codes for hiv-related illnesses *NOTE:* patients with asymptomatic HIV infection status admitted during pregnancy, childbirth, or the puerperium should receive codes: O98.7 and Z21 | 11 | |
| 4292129695 | Selection and sequencing of HIV codes / encounters for testing for HIV | A patient being seen to determine HIV status - 1. Code Z11.4: encounter for screening for human immunodeficiency virus (HIV) 2. Any additional codes for any associated high-risk behavior *NOTE:* an additional code of Z71.7: human immunodeficiency virus (HIV) counseling, may be used if counseling is provided during the encounter for the test | 12 | |
| 4292129696 | Selection and sequencing of HIV codes / encounter for HIV test results | Code Z71.7: human immunodeficiency virus HIV counseling - when a patient returns to be informed of HIV test results | 13 | |
| 4292129697 | Infectious agents as the cause of diseases | Certain infections are classified in chapters other than chapter 1 and no organism is identified as part of the infection code dash in this instance it is necessary to use an additional code from chapter 1 to identify the organism An instructional note will be found at the infection code advising that an additional organism code is required | 14 | |
| 4292129698 | Infections resistant to antibiotics | Code Z16: resistance to antimicrobial drugs - Following the infection code only if the infection code does not identify drug resistance | 15 | |
| 4292795988 | Coding / sepsis | For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection | 16 | |
| 4292795989 | Coding / sepsis - causal organism not specified | Code A41.9: sepsis unspecified organism | 17 | |
| 4292795990 | Coding / severe sepsis | Code R65.2: severe sepsis - should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented | 18 | |
| 4292795991 | Coding / sepsis with negative or inconclusive blood culture | Provider should be queried - negative or inconclusive blood cultures do not preclude a diagnosis of sepsis | 19 | |
| 4292795992 | Urosepsis | Query provider for clarification - A non-specific term Not to be considered synonymous with sepsis Has no default code in the alphabetic index | 20 | |
| 4292795993 | MOD | Multiple organ dysfunction | 21 | |
| 4292795994 | Sepsis with organ dysfunction | If a patient has sepsis and associated acute organ dysfunction or MOD, follow the instructions for coding severe sepsis | 22 | |
| 4292795995 | Clarification of acute organ dysfunction or another medical condition causing sepsis | In the case of a question of whether or not the substance is caused by acute organ dysfunction or another medical condition - query the provider | 23 | |
| 4292795996 | Severe sepsis | Requires minimum of two codes - 1. Underlying systemic infection 2. Followed by R65.2: severe sepsis | 24 | |
| 4293197560 | Septic shock | Generally refers to circulatory failure associated with severe sepsis - represents a type of acute organ dysfunction | 25 | |
| 4293197561 | Coding / septic shock | 1. Code for the systemic infection should be sequenced first 2. Followed by: R65.21: severe sepsis with septic shock 3. ...or: T81.12: post-procedural septic shock 4. Any additional codes for other acute organic dysfunctions should also be assigned CANNOT be assigned as a principal diagnosis | 26 | |
| 4293197562 | Sequencing of severe sepsis / principal diagnosis | 1. Underlying systemic infection should be assigned as principal diagnosis 2. R65.2 appropriate subcategory | 27 | |
| 4293197563 | Sequencing of severe sepsis / severe sepsis develops during an encounter | 1. Code second diagnosis from subcategory R65.2 | 28 | |
| 4293197564 | Severe sepsis on admission | If it is unclear whether severe sepsis was present on admission - provider should be queried | 29 | |
| 4293197565 | Coding / sepsis and severe sepsis with localized infection | 1. Underlying systemic infection assigned first 2. Localized infection assigned as a secondary diagnosis 3.R65.2 subcategory code assigned as secondary diagnosis | 30 | |
| 4293197566 | Coding / sepsis due to post-procedural infection | 1. Post-procedural infection code should be coded first 2. Code for the specific infection 3. From sub-category R65.2 - if patient has severe sepsis 4. Any additional codes for any acute organ dysfunction | 31 | |
| 4293197567 | Coding / post-procedural infection | 1. Code for the precipitating complication should be coded first 2. R6 5.20 severe sepsis without septic shock 3. Any code for systemic infection | 32 | |
| 4293197568 | Coding / post-procedural septic shock | 1. Code for the precipitating complication should be coded first 2. T81.12: Post-procedural septic shock 3. Any code for systemic infection | 33 | |
| 4293249040 | Coding / sepsis associated with non infectious process | 1. Code for the non infectious condition 2. Code for the resulting infection 3. If severe sepsis is present - code from subcategory R6 5.2 4. Any Associated organ dysfunction codes | 34 | |
| 4293424179 | MRSA | Methicillin-resistant staphylococcus aureus | 35 | |
| 4293424180 | Coding / MRSA combo code | Assign appropriate combination code - when patient is diagnosed with an infection due to MRSA and that infection has a combination code that includes the causal organism | 36 | |
| 4293424181 | Coding / MRSA non combo code | Documentation of the current infection do to MRSA that does not have a combination code - 1. Assign appropriate code to identify a condition 2. B95.62: methicillin-resistant staphylococcus aureus (MRSA) | 37 | |
| 4293424182 | MSSA | Methicillin susceptible staphylococcus aureus | 38 | |
| 4293424183 | Colonization /carriage | The condition or state of being colonized or carrying mssa or MRSA | 39 | |
| 4293424184 | Colonization of MSSA or MRSA | Means that MSSA or MRSA is present on or in the body without necessarily causing illness Notes colonization is not necessarily indicative of a disease process or as the cause of a specific condition the patient may have unless documented as such by the provider | 40 | |
| 4293424185 | MRSA screen positive MRSA nasal swab positive | Z 22322 - carrier or suspected carrier of MRSA Z 22321 - carrier or suspected carrier of mssa | 41 | |
| 4293491898 | Chapter 2 - neoplasms | C00 - D49 | 42 | |
| 4293491899 | To properly code a neoplasm | 1. Necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior 2. If malignant, any secondary sites should also be determined | 43 | |
| 4294476417 | Coding neoplasms / overlapping sites | A primary malignant neoplasm that overlaps two or more more contiguous sites should be classified to the sub category code .8: overlapping lesion ...unless the combination is specifically indexed elsewhere | 44 | |
| 4294476418 | Coding neoplasms / multiple neoplasms of same site | For multiple neoplasms of the same site that are not contiguous - codes for each site should be assigned | 45 | |
| 4294476419 | Coding neoplasms / malignant neoplasm of ectopic tissue | Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned | 46 | |
| 4294476420 | Coding using the neoplasm table | 1. The neoplasm table in the alphabetic index should be referenced first 2. However, if the histological term is documented, that term should be referenced first - in order to determine which column in the neoplasm table is appropriate 3. The tabular list should then be referenced to verify that the correct code has been selected from the table and that a more specific code does not exist | 47 | |
| 4294476421 | Z51 | Code used if a patients encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy - as principal diagnosis The diagnosis or problem for which the service is being performed as a secondary diagnosis | 48 | |
| 4294476422 | Coding / treatment directed at malignancy | 1. If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis 2. Exception is code Z51 | 49 | |
| 4294476423 | Coding / treatment of neoplasm secondary site | When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only - the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present | 50 | |
| 4294476424 | Coding / anemia associated with malignancy | When the encounter is for the anemia - code the principal diagnosis followed by the appropriate code for the anemia | 51 | |
| 4294476425 | Coding / anemia associated with chemotherapy, immunotherapy and radiation therapy | When the encounter is for the anemia - code the anemia first followed by the appropriate neoplasm code and the adverse effect | 52 | |
| 4294476426 | Coding / dehydration due to malignancy | When the encounter is for intravenous rehydration - the dehydration is sequence first followed by the code for the malignancy | 53 | |
| 4294476427 | Coding / complication resulting from surgical procedure | When the encounter is for complication resulting from surgical procedure - the complication is principal diagnosis if treatment is directed at resolving the complication | 54 | |
| 4294476428 | Coding / primary malignancy previously excised | When a primary malignancy has been previously excised or eradicated from its site - there is no further treatment directed to that site - there is no evidence of any existing primary malignancy = a code z85 should be used to indicate the former site of the malignancy Any mention of extension, Invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site - may be the principal diagnosis with z85 code as secondary | 55 |
