ED Coding and Reimbursement Alert

Read on for inside info on coding for SARS, sepsis and HIV diagnoses

This issue of ED Coding Alert marks twelve months and counting until the official implementation of ICD-10 in October 2014.  During this year, we will review each chapter of ICD-10 as it relates to the most common diagnoses treated by emergency physicians and throw in a few trick questions just to keep things interesting.

Underline These Infections and Parasitic Diseases (Code Sets A00-B99)

Chapter I includes detailed guidelines for:

1. Human immunodeficiency virus (HIV)

2. Infectious agents as the  cause of diseases classified to other chapters

3. Infections resistant to antibiotics

4. Sepsis, severe sepsis and septic shock

5. Methicillin resistant Staphylococcus aureus (MRSA) conditions

The primary “root” for coding infectious and parasitic diseases is identification of the organism for the disease.  Once the main term for the condition is located, specific subterms take precedence over general subterms.  This chapter also provides input on correct coding of HIV/AIDS. 

Important: Codes from the Infections and Parasitic Disease chapter of ICD-10-CM take precedence over codes from other chapters for the same condition. 

Also, remember that for HIV/AIDS, code only confirmed cases of HIV. Though confirmations does not require documentation of positive serology the provider’s documentation should be clear in the record, says Caral Edelberg, CPC, CPA, CAC, CCS-P, CHC, President, Edelberg and Associates.

For coding purposes, infectious diseases and parasitic diseases are classified here as they are easily transmissible.  The primary axis for coding is the organism responsible for the condition being treated.  The organism is identified first, then a forth character is assigned to indicate an associated condition or site.

EXAMPLE:

Typhoid Fever                                                                  A01.0

Typhoid Fever, unspecified                                           A01.00

Typhoid fever with heart involvement                        A01.02

Typhoid fever with other complications                     A01.09

A thorough review of the Alphabetic Index is necessary to first identify the infection followed by location of the subterm for the organism.  This takes precedence over the more general subterm (acute, chronic, etc.), Edelberg explains.

Start Your Search Severe Acute Respiratory Syndrome (SARS)Here

SARS conditions are specifically identified in ICD-10. SARS is a respiratory condition caused by the coronavirus which often presents with fever and chills, headache and malaise, common symptoms that are included in the code for the condition. 

SARS-related codes are found in section for primary condition:

• B97.21 – SARS associated coronavirus infections (excludes pneumonia)
• J12.81 – Pneumonia due to SARS-associated coronavirus (severe acute respiratory syndrome NOC)

Master Methicillin Resistant S. Aureus (MRSA) ICD-10 Codes

MRSA is often found on the skin and nasal cavities of up to 30% of the population in the US.  When the organism gets into the body through a cut or open area, MRSA can become a life threatening infection.  There are combination codes for MRSA sepsis due to unspecified Staph infection (A41.02) and MRSA pneumonia due to staphylococcus aureus (J15.21).  A code from subcategory Z16.11 MRSA resistant to penicillin’s would typically not be coded in addition to MRSA sepsis or MRSA pneumonia because the MRSA combination code captures both the infectious organism and drug-resistance.  Coders will have to be familiar with the different drug resistant strains to correctly code the combination sets for many of the organisms, says Edelberg.

Ascertain These Sepsis, Severe Sepsis and Septic Shock Diagnoses

Sepsis is an immune response to an infection resulting from bacteria that enter the bloodstream.  This can lead to blood clots or vessel leakage followed by impaired blood flow resulting in vital organ damage.  ED physicians diagnose sepsis and severe sepsis after conducting a complete history and physical to identify the source of the process and to determine how the condition will be identified and treated.  Medical decision making will include laboratory tests, often IV hydration or antibiotic depending on symptoms, some causes of sepsis that may present to the ED include abdominal or pelvic infections, urinary tract infections, diabetic related disorders, etc.

Warning: Watch out for use of the term “urosepsis”.  It is a nonspecific term and is not synonymous with sepsis and has no default code in the ICD-10-CM alphabetic index.  If your ED physicians use this term, query for clarification, Edelberg advises.

An important guideline to remember when coding sepsis is to first report the underlying systemic infection.  If unknown and not further specified, report the code for sepsis, unspecified organism (A41.9)

Assess This Severe Sepsis Guideline

Severe sepsis is a systemic inflammatory condition, which results from an infectious process with evidence of organ dysfunction. Severe sepsis may result in septic shock which is severe sepsis with hypotension requiring IV fluids or vasopressors to maintain normal blood pressure. Sepsis may include additional symptoms such as elevated temperature and/or elevated WBC count. Patients who exhibit low body temperature and low WBC count with severe sepsis often have a poor prognosis and require aggressive management. Severe sepsis should only be reported when clearly documented or an associated acute organ dysfunction is present and documented as related to the sepsis.

The below situations may require a provider query: Clinical evidence of sepsis in the record with the following:

• Blood cultures are negative or inconclusive
• Acute organ dysfunction is not addressed as clearly associated with the sepsis

Documentation: Providers often neglect to provide enough detail in the medical record to allow correct coding of sepsis, severe sepsis or septic shock.  As the medical world move towards ICD-10 implementation, providers will need to be reminded of the importance of complete documentation. If the causal organism is not documented in the medical record, a code from the subcategory of R65.2 should be assigned along with A41.9. 

You should look for some of the following conditions that may indicate severe sepsis and query ED providers if needed for additional clarification:

• High temperature, tachycardia, respiratory rate of >30 breaths per minute ,a; abnormal WBC, hyperglycemia without dx of diabetes; other symptoms of severe infection  along with acute organ dysfunction such as renal insufficiency or severely elevated liver enzymes,
• Severe sepsis as it progresses may result in patient confusion/decreased alertness, renal failure, respiratory failure, hemorrhagic skin rash, extremity mottling and peripheral cyanosis, specific organ failure signs/symptoms.

Severe sepsis requires:

(1)  a code for the underlying systemic infection

(2)  a code from the subcategory R65.2 (Severe sepsis).

For acute associated organ dysfunction additional related codes must be identified, says Edelberg.

Step Up To This Septic Shock Information

Septic shock is generally documented as circulatory failure associated with severe sepsis and is considered a type of organ dysfunction. Septic shock requires an understanding of the following general guidelines:

• If the physician documents septic shock, code the underlying infection first followed by:
           o  R65.21 severe sepsis with septic shock, or
           o  T81.12 post-procedural septic shock
           o  Followed by additional code(s) for any acute organ dysfunctions documented

When an infection is the principle diagnosis it should be reported first followed by the non-infectious condition such as burn, trauma, Edelberg adds.

HIV Infection

Emergency physicians are experienced in treating patients who are HIV positive but coders must use extreme caution when coding for this condition.  First and foremost, you can only code HIV if confirmed as an infection or illness. Assign ICD-10 code B20 only when the condition is confirmed.

In the emergency department, when patients present with another condition and not for treatment for HIV, code first the unrelated condition for which the patient is seeking care followed by code B20 for the patient with a confirmed diagnosis of HIV. Additional diagnoses related to the encounter may be reported as well.

If the patient is asymptomatic and shows no symptoms or HIV-related conditions, code Z21 (Asymptomatic human immunodeficiency virus [HIV] infection status) from the “Factors Influencing Health Status and Contact with Health Services” section) is reported to indicate that the patient is without symptoms.  Once the patient has been diagnosed with any HIV related illness, code B20 should be assigned and codes R75 (Inconclusive laboratory evidence of human immunodeficiency virus [HIV]) or Z21 for asymptomatic HIV should not be assigned, warns Edelberg.