Verified
Chronic kidney disease stage 5 - Code to N18.6 (ESRD) and dialysis status Z99.2
Severe sepsis - Underlying infection + R65.2
Septic shock - Underlying infection + R65.1
Nosocomial infections - Additional code of Y95
HIV infections - Code only confirmed cases (diagnosis sufficient)
Sequencing HIV codes - Admitted for HIV- B20
A/D unrelated- unrelated first then B20
Asymptomatic HIV- Z21
Inconclusive HIV- R75
Previously diagnosed- B20
HIV in pregnancy- O98.7
Asymptomatic HIV in pregnancy- O98.7 + Z21
Encounters for testing of HIV- Z11.4
Return visit for negative test results- Z71.7
Labor pneumonia - Has a unique category
Respiratory condition occurring in more than one place - Coded to the lower anatomic location
Respiratory condition - Code exposure to tobacco
, Gastrointestinal term hemmorrhage - Means ulcers
Gastrointestinal term bleeding - Means gastritis, duodenitis, diverticulosis, diverticulitis
Delivery and pregnancy - 5th or 6th digit represents trimester
Trimesters - 1- less than 14 wks
2- less than 28 wks, more than 14
3- 28 wks thru delivery
Delivery chart codes should include - a) Delivery diagnosis code
b) Outcome of delivery
c)Weeks of gestation
d) Procedure code
Normal delivery code - O80
Weeks of gestation code - Z3A
Complications of ectopic pregnancy and abortions - Require additional codes
Anemia - Code also the cause
Code first the poisoning and under-dosing of medications
If associated with malignancy, code malignancy first
MI documented as nontransmural or subendocardial with a site provided - Code as a subenocardial MI
Subsequent MI within 4 weeks of initial - Code from I22 and I21