In this article we go through the ICD guidelines for HIV and Sepsis disease progression, know about specific guidelines and solve CPC exam quiz by applying the guidelines to get clear idea of the same.
Chapter specific guidelines are the backbone of accurate and effective medical coding.
Understanding these guidelines are pivotal in medical coding realm, not only for AAPC CPC exam but also in live coding in ensuring accuracy, consistency and compliance in the assignment of diagnostic codes.
Chapter – 1 tells about specific guidelines related to Infections and Parasitic Diseases with a code range A00-B99, and also includes Covid 19.
Navigating HIV and sepsis coding guidelines presents a unique challenge due to complexity of disease progression and the need for precise coding at various stages.
For success in AAPC CPC exam we first go through the stages of HIV and Sepsis, know the disease process and see the guidelines.
ICD Guidelines for HIV
First lets know about the HIV.
HIV means Human immunodeficiency virus
AIDS – Acquired immunodeficiency syndrome.
HIV infection has four stages
- Primary illness
- The asymptomatic stage of HIV
- Symptomatic stage of HIV
- Late stage HIV
Primary Illness
Soon after contact with HIV, some persons experience short illness known as Acute HIV infection, primary illness or seroconversion illness. This illness vary with different people ranging from no symptoms to severe illness as they need to see a Doctor.
In this stage the persons are at most infectious state.
The Asymptomatic stage of HIV
The symptoms and acute phase of infection subside and the people enter the Asymptomatic stage – no symptoms but the infection is active, infecting new cells, making copies of itself, damaging immune system’s ability to fight illnesses.
Symptomatic stage of HIV
Without treatment, people with HIV develop secondary infections as your immune system is weakened and can’t fight the infections. Getting ill in one of these ways, indicate Symptomatic stage.
Late stage HIV
In this stage, HIV causes a lot of damage to our immune system, getting ill seriously due to opportunistic infections called AIDS related illness like cancer, tuberculosis and pneumonia.
If HIV is diagnosed in early stages, we can prevent getting into Later stages of HIV, with proper treatment and following a healthy lifestyle.
HIV Coding Guidelines
- Code only confirmed cases, provider documentation of HIV is enough to capture HIV, no need of lab results or evidence.
- Z21 and B20 are the two main codes for HIV.
- Z21 is for HIV – where patient has HIV infection but is asymptomatic, not entered AIDS (symptomatic stage) or HIV related illnesses.
- Synonyms terms to code Z21:
- Asymptomatic HIV
- HIV positive
- HIV test positive
- Known HIV
- B20 is for AIDS – Once the patient has AIDS we have to code as B20 and from then onwards never code it as Z21.
- AIDS
- HIV related illness
- HIV Disease
- AIDS
- Patient with inconclusive HIV serology – code R75 Inconclusive laboratory evidence of human
immunodeficiency virus (HIV)
- Encounter for HIV testing
- To determine the status of HIV, code Z11.4 Encounter for screening for human immunodeficiency virus [HIV]
2. If a patient with signs or symptoms is being seen for HIV testing, code the signs and symptoms.
An additional counseling code Z71.7, Human immunodeficiency virus [HIV] counseling, may be used if counseling is provided during the encounter for the test.
3. Test results negative – Z71.7 Human immunodeficiency virus [HIV] counseling.
Sepsis Guidelines for AAPC CPC exam
It all starts when the microorganism enters the body – Infection.
If infection is untreated turns into Sepsis.
Sepsis
It is a medical emergency, caused by body’s extreme reaction to infection.Body starts to send infection fighting chemicals to entire body, attacking healthy tissues along with infection, life-threatening.
Severe sepsis
Next stage of infection is Septic shock. The sepsis in the body causes low blood pressure and acute organ failure.
Septic shock
This is the last stage characterized by extremely low blood pressure and multi organ failure, circulatory failure
SEPSIS Coding guidelines
Sepsis
- code the underlying systemic infection
- A41.9 if organism is not specified or unspecified.
- Ex- Sepsis due to E.coli – A41.5
- Sepsis – A41.9
Severe sepsis
- Severe sepsis (R65.2-) should be coded when severe sepsis or Sepsis with organ failure is documented.
- Severe sepsis = Sepsis + organ failure
- Codes for Severe sepsis–
- 1st code – Sepsis, unspecified – A41.9
- 2nd code – Severe sepsis – R65.2- and
- Code for associated organ failure (if documented)
- If an organ failure is not associated with sepsis, without mention of severe sepsis then don’t code severe sepsis.
- Sequencing of Severe sepsis
- Severe sepsis on admission – Primary diagnosis is Severe sepsis and follow guidelines to code Severe sepsis
- Severe sepsis in a encounter during the hospital stay and not present on admission – Severe sepsis is coded as secondary diagnosis.
Septic shock
Refers to circulatory failure associated with Severe sepsis (acute organ dysfunction).
- Codes – A419 underlying systemic infection, unspecified.
R65.21 – Severe sepsis with septic shock (or)
T81.12 – Post procedural septic shock (If septic shock is due to procedure)
Code for acute organ dysfunction (Like N17.9 acute renal failure)
Sepsis and Severe sepsis with a localized infection
When the patient comes in with localized infection like Pneumonia or cellulitis.
Severe sepsis present on admission
Codes – Underlying systemic infection, unspecified – A41.9
Localized infection like pneumonia
Severe sepsis
Localized infection present on admission and Severe sepsis developed after admission
Codes – Primary diagnosis is localized infection
Sepsis and Severe sepsis codes.
These are the guidelines for coding HIV and Sepsis.
Now we apply these guidelines by practicing some free AAPC CPC exam questions.
In conclusion, mastering the HIV and Sepsis chapter specific guidelines is not about just passing the AAPC CPC exam but laying foundation for a successful medical coding career.