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Infectious Disease



Ch 1: Infections

ICD-9-CM
  • 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

Notes

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

ICD-9-CM

•Location/Site
•Injury
•Type
•Depth
•Percentage

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

Poisoning:

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

Ch 19: Injury/Burns/Wounds/Poisoning

Notes

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

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