HIV:Human Immunodeficiency Virus
AIDS:( Acquried Immuno Deficiency Syndrome B20)
code only confirm cases .
Asymptomatic HIV and HIV -, Hx of HIV, NON HIV + . we code Z21
HIV in pregancy /childbirth -O98.7+B20+Z3A
HIV for screening-Z11.4
HIV for counselling-Z71.7
Inconclusive HIV serology-R75
HIV Exposure-Z20.6
AIDS related Conditions :Oral through, sepsis, pneumonia, TB, Candiadasis.
When a patient having AIDS and Admitted with Related conditions we have to code firstAIDS and second
code will be AIDS related condition.
AIDS Unrelated conditions: asthma, COPD(Chronic Obstructive Pulmonary disease), Acutekidney failure,
Acute Respiratory failure, heart failure when a patient having AIDS and Admitted with AIDS unrelated
conditions we code first AIDS unrelated conditions and second code will be AIDS
sepsis
1. sepsis is a systemic response to infection, often leading to organ dysfunction.
2. Assign the appropriate code for the underlying infection, followed by a code for the specific type of
sepsis (A40, A41, or A42).
3. If the sepsis is associated with a postprocedural infection, use the appropriate complication code
(T80-T88) as the principal diagnosis, followed by the code for the specific type of sepsis.
4. For severe sepsis without septic shock, assign the code for severe sepsis (A41.9) as the principal
diagnosis, followed by codes for the specific underlying infection.
5.For septic shock, use code R65.21 as the principal diagnosis, followed by codes for the specific
underlying infection.
6.If the patient has severe sepsis or septic shock with a subsequent acute organ dysfunction, assign an
additional code(s) for the specific organ dysfunction(s).
Example:
1.If a patient is admitted with severe sepsis due to a urinary tract infection, the coding would be:
A41.9 Severe sepsis
N39.0 Urinary tract infection, site not specified
2.If the patient develops septic shock due to the urinary tract infection, the coding would be:
R65.21 Severe sepsis with septic shock
N39.0 Urinary tract infection, site not specified
sequencing codes
1.Identify the underlying infection that lead to sepsis and code it first.
Assign the code for the specific type of sepsis based on its causative organism (A40, A41, or A42).
For severe sepsis without septic shock, code the specific underlying infection first, followed by the code
for severe sepsis (A41.9).
For septic shock, code the specific underlying infection first, followed by the code for septic shock
(R65.21).
Sequencing codes in the correct order is crucial for accurate reporting of sepsis. Always code the
underlying infection first, followed by the sepsis code that corresponds to the causative organism. If
severe sepsis or septic shock is present, ensure that it is sequenced correctly after the underlying
infection code.
Example:
, 1.A patient is admitted with pneumonia that progressed to sepsis without septic shock.
J18.9 Pneumonia, unspecified organism (as the underlying infection)
A40.3 Sepsis due to Streptococcus pneumoniae (specific type of sepsis)
2.If the same patient developed septic shock due to pneumonia:
J18.9 Pneumonia, unspecified organism (as the underlying infection)
R65.21 Severe sepsis with septic shock (indicating the progression to septic shock)
sepsis or severe sepsis with a localized infection:
When a patient has sepsis or severe sepsis with a localized infection, the coding would depend on the
level of specificity provided in the medical documentation. The guidelines for coding sepsis with a
localized infection are as follows:
If the documentation specifies the organism causing the localized infection, code the specific organism
first, followed by the appropriate code for sepsis or severe sepsis.
If the organism causing the infection is not specified, use a code for the localized infection without
additional code(s) for sepsis or severe sepsis.
If the patient's condition progresses to sepsis or severe sepsis with organ dysfunction, additional codes
would be needed to indicate the organ dysfunction(s).
Example 1:
1.A patient is diagnosed with cellulitis of the leg and develops severe sepsis due to a bacterial infection.
L03.115 Cellulitis of right lower limb (localized infection)
A41.9 Sepsis, unspecified organism (severe sepsis)
Example 2:
A patient is diagnosed with an abscess in the abdomen and develops sepsis without severe organ
dysfunction.
K65.1 Peritoneal abscess (localized infection)
A40.3 Sepsis due to Streptococcus 2neumonia (sepsis without severe organ dysfunction)
In both examples, the localized infection is coded first, followed by the code for sepsis/severe sepsis. If
organ dysfunction had been present in Example 1, additional codes would be used to indicate the
specific organ(s) involved.
Sepsis due to postprocedural infection
When a patient develops sepsis due to a postprocedural infection, the coding would depend on the
specific details provided in the medical documentation. The coding guidelines for sepsis due to a
postprocedural infection are as follows:
Code the specific postprocedural infection as the principal diagnosis.
If the postprocedural infection leads to sepsis without septic shock, code the specific postprocedural
infection first, followed by the code for sepsis (A41.9).
If the postprocedural infection leads to septic shock, code the specific postprocedural infection first,
followed by the code for septic shock (R65.21).
Example:
1.A patient undergoes abdominal surgery and develops sepsis due to a postprocedural infection at the
surgical site.
T81.4XXA Infection following a procedure, initial encounter (as the specific postprocedural infection)
A41.9 Sepsis, unspecified organism (if sepsis without septic shock)
2.If the patient’s condition progresses to septic shock due to the postprocedural infection:
T81.4XXA Infection following a procedure, initial encounter (as the specific postprocedural infection)
R65.21 Severe sepsis with septic shock (to indicate the progression to septic shock)
In both examples, the specific postprocedural infection is coded first, followed by the appropriate code
for sepsis or septic shock, depending on the severity of the patient’s condition. Additional codes would
be used to indicate any organ dysfunction or complications, if present.
AIDS:( Acquried Immuno Deficiency Syndrome B20)
code only confirm cases .
Asymptomatic HIV and HIV -, Hx of HIV, NON HIV + . we code Z21
HIV in pregancy /childbirth -O98.7+B20+Z3A
HIV for screening-Z11.4
HIV for counselling-Z71.7
Inconclusive HIV serology-R75
HIV Exposure-Z20.6
AIDS related Conditions :Oral through, sepsis, pneumonia, TB, Candiadasis.
When a patient having AIDS and Admitted with Related conditions we have to code firstAIDS and second
code will be AIDS related condition.
AIDS Unrelated conditions: asthma, COPD(Chronic Obstructive Pulmonary disease), Acutekidney failure,
Acute Respiratory failure, heart failure when a patient having AIDS and Admitted with AIDS unrelated
conditions we code first AIDS unrelated conditions and second code will be AIDS
sepsis
1. sepsis is a systemic response to infection, often leading to organ dysfunction.
2. Assign the appropriate code for the underlying infection, followed by a code for the specific type of
sepsis (A40, A41, or A42).
3. If the sepsis is associated with a postprocedural infection, use the appropriate complication code
(T80-T88) as the principal diagnosis, followed by the code for the specific type of sepsis.
4. For severe sepsis without septic shock, assign the code for severe sepsis (A41.9) as the principal
diagnosis, followed by codes for the specific underlying infection.
5.For septic shock, use code R65.21 as the principal diagnosis, followed by codes for the specific
underlying infection.
6.If the patient has severe sepsis or septic shock with a subsequent acute organ dysfunction, assign an
additional code(s) for the specific organ dysfunction(s).
Example:
1.If a patient is admitted with severe sepsis due to a urinary tract infection, the coding would be:
A41.9 Severe sepsis
N39.0 Urinary tract infection, site not specified
2.If the patient develops septic shock due to the urinary tract infection, the coding would be:
R65.21 Severe sepsis with septic shock
N39.0 Urinary tract infection, site not specified
sequencing codes
1.Identify the underlying infection that lead to sepsis and code it first.
Assign the code for the specific type of sepsis based on its causative organism (A40, A41, or A42).
For severe sepsis without septic shock, code the specific underlying infection first, followed by the code
for severe sepsis (A41.9).
For septic shock, code the specific underlying infection first, followed by the code for septic shock
(R65.21).
Sequencing codes in the correct order is crucial for accurate reporting of sepsis. Always code the
underlying infection first, followed by the sepsis code that corresponds to the causative organism. If
severe sepsis or septic shock is present, ensure that it is sequenced correctly after the underlying
infection code.
Example:
, 1.A patient is admitted with pneumonia that progressed to sepsis without septic shock.
J18.9 Pneumonia, unspecified organism (as the underlying infection)
A40.3 Sepsis due to Streptococcus pneumoniae (specific type of sepsis)
2.If the same patient developed septic shock due to pneumonia:
J18.9 Pneumonia, unspecified organism (as the underlying infection)
R65.21 Severe sepsis with septic shock (indicating the progression to septic shock)
sepsis or severe sepsis with a localized infection:
When a patient has sepsis or severe sepsis with a localized infection, the coding would depend on the
level of specificity provided in the medical documentation. The guidelines for coding sepsis with a
localized infection are as follows:
If the documentation specifies the organism causing the localized infection, code the specific organism
first, followed by the appropriate code for sepsis or severe sepsis.
If the organism causing the infection is not specified, use a code for the localized infection without
additional code(s) for sepsis or severe sepsis.
If the patient's condition progresses to sepsis or severe sepsis with organ dysfunction, additional codes
would be needed to indicate the organ dysfunction(s).
Example 1:
1.A patient is diagnosed with cellulitis of the leg and develops severe sepsis due to a bacterial infection.
L03.115 Cellulitis of right lower limb (localized infection)
A41.9 Sepsis, unspecified organism (severe sepsis)
Example 2:
A patient is diagnosed with an abscess in the abdomen and develops sepsis without severe organ
dysfunction.
K65.1 Peritoneal abscess (localized infection)
A40.3 Sepsis due to Streptococcus 2neumonia (sepsis without severe organ dysfunction)
In both examples, the localized infection is coded first, followed by the code for sepsis/severe sepsis. If
organ dysfunction had been present in Example 1, additional codes would be used to indicate the
specific organ(s) involved.
Sepsis due to postprocedural infection
When a patient develops sepsis due to a postprocedural infection, the coding would depend on the
specific details provided in the medical documentation. The coding guidelines for sepsis due to a
postprocedural infection are as follows:
Code the specific postprocedural infection as the principal diagnosis.
If the postprocedural infection leads to sepsis without septic shock, code the specific postprocedural
infection first, followed by the code for sepsis (A41.9).
If the postprocedural infection leads to septic shock, code the specific postprocedural infection first,
followed by the code for septic shock (R65.21).
Example:
1.A patient undergoes abdominal surgery and develops sepsis due to a postprocedural infection at the
surgical site.
T81.4XXA Infection following a procedure, initial encounter (as the specific postprocedural infection)
A41.9 Sepsis, unspecified organism (if sepsis without septic shock)
2.If the patient’s condition progresses to septic shock due to the postprocedural infection:
T81.4XXA Infection following a procedure, initial encounter (as the specific postprocedural infection)
R65.21 Severe sepsis with septic shock (to indicate the progression to septic shock)
In both examples, the specific postprocedural infection is coded first, followed by the appropriate code
for sepsis or septic shock, depending on the severity of the patient’s condition. Additional codes would
be used to indicate any organ dysfunction or complications, if present.
