Research a malignancy, common infectious, endocrine disease, or blood condition. Describe the disease/condition including the signs/symptoms and treatment. Emphasize what the coder needs to know to accurately code this disease/condition and discuss any specific guidelines. Be sure to choose a condition that has not already been posted. Include the name of the disease in the post title.
Module 02 – Coding Infectious Disease, Neoplasms, Endocrine and Disorders of Blood
The following provides an overview of the chapter specific guidelines. This overview will provide a brief introduction. These guidelines will be further explored in this week’s Live Classroom and Reading assignments.
Please note that the textbook chapters do not correlate with the codebook chapters. The reading below lists codebook chapters being covered in the assigned textbook reading and chapter review exercises this week.
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), covers the coding of communicable, infectious and parasitic diseases as well as sepsis, severe sepsis and septic shock. The guidelines provide direction as how to code HIV and AIDS along with sepsis, infectious organisms, antibiotic resistance including MRSA. Pay close attention to sequencing rules of HIV, AIDS and sepsis codes.
- If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related conditions.
- If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the principal diagnosis. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions.
- Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” or similar terminology. Do not use this code if the term “AIDS” is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases.
- For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.
- A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.
- The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification
See the ICD-10-CM Codebook Section I.C.1 for the full guidelines. Refer to them often as you code.
Chapter 2: Neoplasms (C00-D49), contains the classification of all types of neoplasms: malignant, benign, uncertain behavior, and unspecified nature using the Neoplasm table located immediately after the alphabetic index (verify neoplasm codes in the tabular as usual). Make sure to review the chapter specific guidelines as well as the instructional note in at the beginning of the neoplasm table.
- Neoplasms are classified according to behavior (malignant, benign, etc.), anatomical site and morphology (carcinoma, leukemia, etc.). Carefully examine the guidelines when coding a history of neoplasm. Make sure to distinguish between primary and secondary neoplasms and apply the neoplasm sequencing rules.
- Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm, it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary (metastatic) sites should also be determined.
- The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table.
For example, if the documentation indicates “adenoma,” refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site.
- It is important to select the proper column in the table that corresponds to the type of neoplasm. The Tabular List should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.
See the ICD-10-CM Codebook Section I.C.2 for the full guidelines. Refer to them often as you code.
Chapter 3: Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89), covers the coding of various types of diseases of blood and blood-forming organs including anemia, coagulation disorders and diseases of WBCs. This is one of the shortest chapters in ICD. These guidelines are reserved for future guideline expansion so the coder will rely on the General Coding Guidelines and instructional notes in the tabular.
Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) discusses the coding of diseases of the endocrine glands, nutritional disorders, and metabolic and immunity disorders. It is important that you are able to describe the different types of diabetes and how the type of diabetes impacts the code selection in ICD-10-CM. Pay particular attention to the guidelines in reference to sequencing and secondary diabetes and coding of hypo and hyperglycemia.
- The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.
- More than one codes within a particular category may be assigned as necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08 – E13 as needed to identify all of the associated conditions that the patient has.
- If the type of diabetes mellitus is not documented in the medical record the default is E11.-, Type 2 diabetes mellitus.
- If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned. Code Z79.4, Long-term (current) use of insulin, or Z79.84, Long term (current) use of oral hypoglycemic drugs, should also be assigned to indicate that the patient uses insulin or hypoglycemic drugs.
- Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.
- Codes under categories E08, Diabetes mellitus due to underlying condition, E09, Drug or chemical induced diabetes mellitus, and E13, Other specified diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus.
- Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning).
See the ICD-10-CM Codebook Section I.C.1 for the full guidelines. Refer to them often as you code.