HIM1222C General Coding Guidelines

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Signs & Symptoms
Codes that describe symptoms and signs as opposed to diagnosis, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the providers.
Conditions that are an integral part of a disease
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification
Conditions that are not an integral part of a disease process
Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.
Multiple coding for a single condition
-Sequencing rule is the same as the etiology/manifestation pair - ,
-"Code First": codes that may be an underlying cause
Multiple codes may be needed for late effects, complication codes, and obstetric codes to more fully describe a condition
Acute and Chronic Conditions
If the same condition is described as both acute (subacute) and chronic, and seperate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) first.
Combination Code
A combination code is a single code used to classify:
-2 diagnoses
-A diagnosis with an associated secondary process or manifestation
-A diagnosis with an associated complication
Late Effects
-Residual Effect (condition produced) after the acute phase of an illness or injury has terminated.
-No time limit (months or years)
-Condition or nature of the late effect is sequenced 1st and the late effect is sequenced second
Impending or Threatened Condition
-Code any condition described at the time of discharge as "impending" or "threatened" as follows:
-If it did occur, code as confirmed diagnosis
-If it didn't occur, reference the alphabetic indenx to determine if the condition has a subentry term for "impending" and for "threatened"
-If subterms are listed, assign the given code
-If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened.
AIDS
see pp. 20-22
042.XX
795.71 - inconclusive HIV serology
V08 - asymptomatic HIV *NOT AIDS*
647.6X - HIV infection in pregnancy, childbirth, puerperium
V73.89 - encounter to determine status
V65.44 - may be used if counseling is provided during the encounter for the test (also use for when a patient comes back for results and it's negative)
Septicemia
Refers to a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi, or other organisms
Systemic Inflammatory Response Syndrome
trauma/burns, or other insult (cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis
Sepsis
Generally refers to SIRS due to infection
Severe Sepsis
refers to sepsis with associated acute organ dysfunction
Septicemia, SIRS, Severe Sepsis
-Requires a minimum of 2 codes
-One fore underlying cause (infection or trauma)
-One from a subcategory 995.9
-Sepsis & Severe Sepsis require a code for the systemic infection (038.XX, 112.5, ect.) and either 995.91 or 995.92
-pp. 22-26
Septic Shock
Refers to circulatory failure associated with severe sepsis, and, therefore, it represents a type of acute organ dysfunction