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Infectious Disease

Ch 1: Infections

  • Manifestation
  • Condition

Ch 1: Infections

ICD-10-CM Requirements

HIV, document:

  •  Confirmation doesn’t require positive serology; provider’s diagnostic statement that the patient is HIV positive or has an HIV related illness is sufficient.

Sepsis, document:

  • Specify the underlying systemic infection (specify if post-procedural) or causal organism
  • Any acute organ dysfunction.

MRSA, document:

  • Infection due to MRSA and any causal organism

Ch 1: Infections


The word “Certain” in this chapter stresses the fact that localized infections will be located in the pertinent body system (i.e. UTI is classified in Chapter 14).

Ch 19: Injury/Burns/Wounds/Poisoning



Ch 19: Injury/Burns/Wounds/Poisoning

ICD-10-CM Requirements

General Documentation:

  • Location/site
  •  Laterality
  •  Sequence most serious injury as determined by the provider
  •  Superficial injury/abrasions or contusions should be specified if associated with more severe injuries of the same site.
  • Injury with damage to nerve/blood vessels: document primary injury, followed by nerves and/or blood vessels. (If the primary injury is to the nerve/blood vessel code as primary.)

Fractures, document:

  •  Location (specify site of the fracture, e.g. hip fracture – subtrochanteric fracture of right femur)
  •  Open or Closed
  • Late Effect
  •  Type:
    – Displaced or non-displaced
  •  Laterality
  •  Gustilo classification system (specify classification) of open fractures
  •  Encounter type:
    – Initial (during active treatment)
    – Subsequent (i.e. specify routine or delayed healing, non-union, malunion)
    – Sequela

Burns, document:
Distinguish between ‘burns’ and ‘corrosions’

  • If thermal burn, specify heat source (i.e. electricity or radiation)
  • Specify if due to chemicals.

Wounds, document:

  • Location/site
  • Depth
  • Type:
    – Bite
    – Laceration
    – Puncture
  • With or without foreign body


  • Identify define Drug or Chemical
  • Specify: Adverse effect, Poisoning, Under-dosing or Toxic effects

Ch 19: Injury/Burns/Wounds/Poisoning


Most codes may require a 7th
character for encounter type. Burns:

  • Sequence code to highest degree of burn(s).
  • Non-healing burns coded as Acute Burn (Necrosis of non- healed burn coded as non- healed burn).
  • Infected burn site, use additional code for infection.
  • Burns are classified by degree/depth, extent and age