ICD-10-CM Documentation 2019: Essential Charting

Guidance to Support Medical Necessity

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ICD-10-CM Documentation 2019:
Essential Charting Guidance to Support Medical Necessity

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Acknowledgements
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 CONTENTS

Introduction
Chapter 1: Infectious and Parasitic Diseases
Chapter 2: Neoplasms
Chapter 3: Diseases of the Blood and Blood-Forming Organs
Chapter 4: Endocrine, Nutritional and Metabolic Diseases, and Immunity
Disorders
Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders
Chapter 6: Diseases of the Nervous System
Chapter 7: Diseases of the Eye and Adnexa (H00-H59)
Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95)
Chapter 9: Diseases of the Circulatory System
Chapter 10: Diseases of the Respiratory System
Chapter 11: Diseases of the Digestive System
Chapter 12: Diseases of the Skin and Subcutaneous Tissue
Chapter 13: Complications of Pregnancy, Childbirth, and the Puerperium
Chapter 14: Diseases of the Genitourinary System
Chapter 15: Diseases of the Musculoskeletal System and Connective Tissue
Chapter 16: Congenital Anomalies
Chapter 17: Certain Conditions Originating in the Perinatal Period
Chapter 18: Symptoms, Signs, Ill-Defined Conditions
Chapter 19: Injury, Poisoning, and Certain Other Consequences of External
Causes

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Chapter 20: Factors Influencing Health and Contact with Health Care Services
Chapter 21: External Causes of Morbidity
Appendix A: Documentation Coding Checklists
Appendix B: Clinical Documentation Improvement (CDI) Checklists
Appendix C: Glossary

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 INTRODUCTION

Introduction
Documentation is one of the central elements that underlie patient care, coding and billing
for patient care, and an effective compliance plan. Many diseases, disorders, injuries, other
conditions and even signs and symptoms require specific documentation to be compliant with
the code structure and provide diagnosis coding to the highest level of specificity for accurate
reporting and reimbursement. An ongoing review of documentation practices will help to
determine if corrective changes are needed. The ICD-10-CM Documentation: Essential
Charting Guidance to Support Medical Necessity is designed to address this need.

Documentation and Coding

In this book, three aspects of ICD-10-CM coding and documentation are addressed. The
first relates to documentation requirements. Before actual medical record documentation can
be analyzed, physicians and coders must understand the ICD-10-CM requirements for
commonly reported signs, symptoms, diseases, and other medical conditions. Frequently,
codes capture specific information about the condition itself. For example, strep infections of
the throat and tonsils must be specifically identified as strep throat or strep tonsillitis; and for
patients with strep tonsillitis, the condition must be specified as acute or acute recurrent.

Codes may also capture a disease and related conditions. For example, there are combination
codes that capture the type of diabetes and specific manifestations or complications, such as
Type 2 diabetes with hypoglycemia which must also be specified as with or without coma.
Some codes capture a condition and common symptoms, such as intervertebral disc disorders
with radiculopathy. ICD-10-CM Documentation: Essential Charting Guidance to Support
Medical Necessity covers many commonly reported diagnoses and reviews the necessary
documentation elements so that providers and coders have a good understanding of what
documentation is required based on the available codes for the condition.

The next aspect of coding and documentation addressed is the analysis component. Each

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condition covered in the book includes a bulleted list of coding and documentation elements.
This list is designed to be used for actual documentation analysis. A documentation and
coding example is provided with bolding of the portion of the documentation that captures
the information required for ICD-10-CM code assignment. Coders will need to remember
that physicians do not always document using exactly the same terminology in the code
descriptor. However, that does not mean that a specific code cannot be identified.

The physician may use an alternate term that describes the same condition with the necessary
level of specificity. So coders will need to rely on and enhance their knowledge of medical
terminology and synonymous terms. In addition, coders will need to rely on coding
instructions in the Alphabetic Index and Tabular List as well as the ICD-10-CM Official
Guidelines for Coding and Reporting to determine whether the most specific code can be
assigned from the documentation provided or whether the physician will need to queried.

The last aspect of coding and documentation that is addressed is documentation

improvement. Several documentation checklists are provided in Appendix B for physician
feedback related to specific conditions. These checklists can be used to identify any missing
documentation elements required to assign the most specific code. Information contained in
the checklists can be compiled for each physician and any documentation deficiencies
identified. Documentation and coding checklists for conditions not addressed in this book
can also be created for other conditions using the formats of the checklists provided. There
are a few different formats and styles of checklists so users can determine which style works
best for their practice and then create additional checklists using that format and style.

In addition to the coding and documentation checklists there are clinical documentation
improvement bulleted lists for three conditions that are often lacking sufficient
documentation in the inpatient setting. The information in these lists identifies common
indicators of the condition so that the physician can be queried to determine if the condition
should be included as a diagnosis in the medical record or can be coded to a more specific
diagnosis.

Documentation and Compliance

Complete and accurate provider documentation is a continuous concern for physicians and
hospitals alike. In addition to supporting quality patient care and serving as a legal document
to verify the services provided, provider documentation is also needed to support correct
coding initiatives, coding and documentation audits, and Medicare oversight reviews.

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The Social Security Act and the Centers for Medicare & Medicaid Services (CMS)
regulations require that services be medically necessary, have documentation to support the
claims, and be ordered by physicians. Consistent, current and complete documentation in the
treatment record is an essential component of quality patient care according to the National
Committee for Quality Assurance. Specific documentation criteria are required for inpatient
medical records by the Joint Commission on Accreditation of Healthcare Organizations and
the federal Conditions of Participation. In addition to accreditation standards and federal
regulations, medical record documentation must also comply with state licensure regulations
and payer policies, as well as professional practice standards. Compliance and accurate
reimbursement depend on the correct application of codes, which is based on provider
documentation. In addition to the reimbursement implications, provider documentation is
also used in quality improvement initiatives.

The codes reported on health insurance claims must be supported by the documentation in
the medical record. Most payers require reasonable documentation that services are consistent
with the insurance coverage provided. In one year, for example, the Office of Inspector
General (OIG) found that 43.7 percent of errors were due to insufficient documentation,
posing a significant compliance risk. Recovery Audit Contractors and Medicare
Administrative Contractors reviews continue to identify numerous erroneously paid claims
due to a high incidence of “insufficient documentation.”

Medicare specifically requires that any services billed be supported by documentation that
justifies payment. The Centers for Medicare & Medicaid Services (CMS) has implemented
numerous corrective actions to reduce improper payments along with efforts to educate
providers about the importance of thorough documentation to support the medical necessity
of services and items. CMS review contractors identify and recover improper payments made
due to insufficient documentation—the review determines that the documentation is not
sufficient to support the provided service or that it was medically necessary. For example, a
pilot study estimated that additional documentation would have reduced the amount of
improper payments identified in 2010 by approximately $956 million.

Medical record documentation must comply with all legal/regulatory requirements applicable
to Medicare claims. Documentation guidelines identify the minimal expectations of
documentation by providers for payment of services to the Medicare program. Additional
documentation is often required by state or local laws, professional guidelines, and the
policies of a practice or facility. In general, medical record documentation that specifically

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justifies the medical necessity of services is necessary to support approval when those services
are reviewed. Services are considered medically necessary if the documentation indicates they
meet the specific requirements for medical necessity.

The key to ensuring appropriate documentation hinges on understanding how much depends
on the quality and completeness of provider documentation in the medical record. Providers
typically do not know the specific type of documentation needed to code various diseases and
disorders accurately, so education is also a key factor. Prior to conducting provider education,
it is important to know the extent and type of documentation in the medical record.
Conducting a provider documentation assessment of medical records will identify key areas of
risk and focus education efforts.

Documentation is central to patient care, billing for patient care, and an effective compliance
plan. Accurate patient record documentation is a key component of the compliance plan, as it
provides the justification necessary to support claims payment. Increased scrutiny of provider
documentation by auditors has added even greater emphasis to the importance of identifying
documentation deficiencies, correcting them, and ensuring proper documentation for every
case. One of the key components of an effective compliance program for physician practices is
the implementation of a system to audit and monitor an organization’s practices.

Overview of ICD-10-CM Documentation: Essential Charting

Guidance to Support Medical Necessity
The ICD-10-CM Documentation: Essential Charting Guidance to Support Medical Necessity is
designed around ICD-10-CM with a documentation and coding chapter for each ICD-10-
CM chapter.

Chapter Introduction
Introductory information for each chapter covers general information about the chapter. A
table is provided showing the chapter coding blocks which are the ranges of 3 character
categories that cover related diagnoses within the chapter. Review of this table provides
coders and physicians with information about the organization of that specific chapter.

The introduction also covers chapter level instructional notes, including includes and excludes
notes. Chapter level includes notes further define or give examples of the content of the
chapter. Excludes notes indicate that certain diseases, injuries or other conditions are
excluded from or not coded in the chapter. There are two types of excludes notes in ICD-10-
CM designated as Excludes1 and Excludes2 which are defined as follows:

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• Excludes1 – A type 1 excludes note is a pure excludes note. In general, it means “NOT
CODED HERE”. An Excludes1 note indicates that the code excluded should rarely be
used at the same time as the code above the Excludes1 note. An Excludes1 is used when
two conditions cannot occur together, such as a congenital form versus an acquired form
of the same condition. There are a few exceptions when both conditions may be coded
such as a sequela from a prior CVA and a new CVA or chondromalacia of the patella as
well as the femur.

• Excludes2 – A type 2 excludes note represents “NOT INCLUDED HERE”. An

Excludes2 note indicates that the condition excluded is not part of the condition
represented by the code, but a patient may have both conditions at the same time. When
an Excludes2 note appears under a code, it is acceptable to use both the code and the
excluded code together, when appropriate.

Chapter Guidelines
Following the introduction, the ICD-10-CM Official Guidelines for Coding and Reporting for
the chapter are reviewed. The chapter guidelines provide information on assigning codes
from the chapter which often includes information related to documentation. Many coders
think of the guidelines primarily as instructions on assignment and sequencing of codes, but
there are many references to information that must be included in the documentation to
allow assignment of specific codes. In addition, the coding guidelines often indicate when the
physician should be queried for additional information related to the diagnosis. So, the
chapter-specific guidelines are an important tool that must be used to ensure that the
documentation supports assignment of a specific code.

General Documentation Requirements

For each chapter, general documentation requirements are covered. Many chapters in ICD-
10-CM have documentation requirements that relate to the entire chapter or to many code
categories in the chapter. Examples of the types of information covered in the general
documentation requirements include:

• Site specificity, such as proximal or distal, or upper/middle/lower lobe

• Laterality (right, left, bilateral)

• Combination codes that capture:

– Etiology and manifestation

– Related conditions

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 – Disease, injury or other medical condition and complications

– Diseases or other medical conditions and common signs or symptoms

• Identification of the fetus affected by certain complications of pregnancy, childbirth and

puerperium in multiple gestation pregnancies

• Identification of the trimester for complications occurring during pregnancy

• Increased specificity related to histologic behavior of certain neoplasms

• Episode of care (initial, subsequent, sequela) for injuries, poisoning, external causes and
other conditions

• Increased specificity related to type of injury

• Use of fracture classification systems (Gustilo, Salter-Harris, Neer)

• Intraoperative and postprocedural complications

• Reclassification of codes into different categories or chapters

• Revised terminology

Chapter-Specific Documentation Requirements

In this section, code categories, subcategories, and subclassifications for some of the more
frequently reported diseases, disorders, or other conditions in each ICD-10-CM chapter are
reviewed. Specific documentation requirements are identified. The focus is on conditions
with specific clinical documentation requirements. Although not all codes with significant
documentation requirements are discussed, this section provides a representative sample of
the type of documentation needed for diseases, disorders, or other conditions coded in the
chapter. The section is organized alphabetically by the ICD-10-CM code category,
subcategory, or subclassification depending on whether the documentation affects only a
single code or an entire subcategory or category.

The condition reported by the category, subcategory, or code is discussed, followed by a

bulleted list identifying the specific elements that must be captured to allow assignment of
the most specific code. A scenario provides an example of the documentation required to
capture the most specific code and the scenario is also coded. Coding notes are provided that
discuss any guidelines, includes/excludes notes and other information that affected the code
assignment for the scenario.

Quiz
A self-assessment quiz is provided at the end of the chapter. The quiz covers general and

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chapter specific guidelines, documentation requirements, and code assignment for the
conditions discussed in the chapter. Answers and rationales are listed on the pages following
the quiz in each chapter.

Appendixes
There are three appendixes. Appendix A provides checklists for common diagnoses and other
conditions to be used for documentation review of current records to help identify
documentation deficiencies. Appendix B provides bulleted lists that can be used for clinical
documentation improvement. Appendix C provides a glossary of medical terminology
encountered in the book.

Other Recommended Resources

The ICD-10-CM Documentation: Essential Charting Guidance to Support Medical Necessity may
be used alone; however, the most benefit will be derived when the book is used with other
coding resources. It is recommended that the book be used in conjunction with the most
recent ICD-10-CM Code Set and ICD-10-CM Official Guidelines for Coding and Reporting. A
comprehensive medical dictionary is also recommended.

Summary
Patient care, documentation, coding and compliance go hand-in-hand. It is not possible to
assign the most specific and most appropriate diagnosis code without complete, detailed
documentation related to the patient’s disease, injury, or other reason for the encounter/visit.
Documentation must also support the medical necessity of any services provided or
procedures performed. Detailed, consistent, complete documentation in the medical record is
one of the cornerstones of compliance. In addition, the effect of documentation on
reimbursement cannot be overemphasized. Failure to support the medical necessity of the
services or procedures provided or performed can result in loss of reimbursement, financial
penalties, and other sanctions. Because of the specificity of ICD-10-CM codes and
requirements by health plans to support the services billed, current documentation must be
reviewed, documentation deficiencies identified, and a corrective action plan initiated. This
book is designed to help coders, physician practices, and other health care providers
understand the documentation requirements and prepare for improved documentation to
support the services billed and the severity of the patient’s condition.

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14
 Chapter 1
INFECTIOUS AND PARASITIC
DISEASES

Introduction
Codes for infectious and parasitic diseases are located in Chapter 1. Infectious and parasitic
diseases are those which are generally recognized as communicable or transmissible.
Conditions covered in this chapter include scarlet fever, sepsis due to an infectious organism,
meningococcal infection, and genitourinary tract infections. The table below shows the blocks
within Chapter 1 Certain Infectious and Parasitic Diseases and illustrates the general layout
by which these conditions are classified.

ICD-10-CM Blocks

A00-A09 Intestinal Infectious Diseases

A15-A19 Tuberculosis

A20-A28 Certain Zoonotic Bacterial Diseases

A30-A49 Other Bacterial Diseases

A50-A64 Infections with a Predominantly Sexual Mode of Transmission

A65-A69 Other Spirochetal Diseases

A70-A74 Other Diseases Caused by Chlamydiae

A75-A79 Rickettsioses

A80-A89 Viral and Prion Infections of the Central Nervous System

A90-A99 Arthropod-Borne Viral Fevers and Viral Hemorrhagic Fevers

B00-B09 Viral Infections Characterized by Skin and Mucous Membrane Lesions

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 B15-B19 Viral Hepatitis

B20 Human Immunodeficiency Virus (HIV) Disease

B25-B34 Other Viral Diseases

B35-B49 Mycoses

B50-B64 Protozoal Diseases

B65-B83 Helminthiases

B85-B89 Pediculosis, Acariasis and Other Infestations

B90-B94 Sequela of Infectious and Parasitic Diseases

B95-B97 Bacterial and Viral Infectious Agents

B99 Other Infectious Diseases

Not all infectious and parasitic diseases are found in chapter 1. Localized infections are found
in the respective body system chapters.

Exclusions
Reviewing the chapter level exclusions provides information on which conditions may or may
not be reported together, as well as some information on infectious conditions found in other
chapters.

Excludes1 Excludes2

Certain localized infections are reported Carrier or suspected carrier of infectious

with codes from body system related disease (Z22.-)
chapters Infectious and parasitic diseases complicating
pregnancy, childbirth, and the puerperium
(098.-)
Infections and parasitic diseases specific to the
perinatal period (P35-P39)
Influenza and other acute respiratory infections
(J00-J22)

Chapter Guidelines
Detailed official coding and reporting guidelines are provided for:

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• Human immunodeficiency virus (HIV)

• Infectious agents as the cause of diseases classified to other chapters

• Infections resistant to antibiotics

• Sepsis, severe sepsis, and septic shock

• Methicillin resistant Staphylococcus aureus (MRSA) conditions

Human Immunodeficiency Virus (HIV) Infections

Guidelines and corresponding ICD-10-CM codes for reporting HIV infections and testing
for HIV are listed on the following page.

• Code only confirmed cases. This does not require documentation of positive serology or
culture for HIV. The provider’s diagnostic statement that the patient is HIV positive or
has an HIV-related illness is sufficient.

• Selection and sequencing of HIV codes:

– Patient admitted for HIV-related condition. The principal diagnosis should be acquired
immune deficiency syndrome (AIDS) (B20) followed by additional diagnosis codes for
all reported HIV-related conditions.

– Patient with AIDS or HIV-related disease admitted for unrelated condition. The code
for the unrelated condition (such as an injury) should be the principal diagnosis
followed by the code for AIDS (B20), followed by additional diagnosis codes for all
HIV-related conditions that are reported.

– Newly diagnosed patient. Whether the patient is newly diagnosed or has had previous
admissions/encounters for HIV conditions does not affect the sequencing decision.

– Asymptomatic HIV. The code for asymptomatic HIV infection status (Z21) is
reported when the patient is asymptomatic but the physician has documented that the
patient is HIV positive, known HIV, HIV test positive, or any similar terminology.
These codes are not used if the physician documents that the patient has AIDS, or
when the patient has any HIV-related illness or any conditions resulting from the HIV
positive status. In these cases, the code for AIDS is used (B20).

– Patients with inconclusive HIV serology. Inconclusive serology without a definitive

diagnosis and without any manifestations associated with HIV is assigned the code for
inconclusive laboratory evidence of HIV (R75).

– Previously diagnosed HIV-related illness. Once the patient has developed an HIV-

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 related illness, the code for AIDS (B20) is assigned on every subsequent
admission/encounter. Patients previously diagnosed with an HIV-related illness are
never assigned the codes for inconclusive laboratory evidence of HIV (R75) or
asymptomatic HIV infection status (Z21).

– HIV related illness in pregnancy, childbirth and the puerperium. During pregnancy,
childbirth and the puerperium, a patient seen for an HIV-related illness is assigned the
principal diagnosis code of O98.7-, Human immunodeficiency [HIV] disease
complicating pregnancy, childbirth and the puerperium, from Chapter 15, which is
sequenced first followed by the code for AIDS (B20) and then the HIV-related illness.

– A patient with asymptomatic HIV infection status during pregnancy, childbirth or the
puerperium is assigned a principal diagnosis code from Chapter 15 of O98.7-followed
by the code for asymptomatic HIV infection status (Z21).

– Encounter for HIV testing. A patient being seen to determine his or her HIV status is
assigned code Z11.4, Encounter for screening for human immunodeficiency virus
[HIV]. Additional codes should be assigned for any associated high risk behavior (e.g.,
Z72.5-).

– Encounter for HIV testing with signs/symptoms. The code(s) for the signs/symptoms
are assigned. An additional code may be assigned if counseling for HIV is provided
(Z71.7) during the encounter for the testing.

– Return encounter for HIV test results. If the results are negative, the code for HIV
counseling is assigned (Z71.7). If the results are positive, use the guidelines above to
select the appropriate code(s).

Infectious Agents as the Cause of Diseases Classified to Other Chapters

Certain infections, particularly localized infections, are reported with codes from the
corresponding body system chapter. Many of these codes do not identify the organism, so a
second code from Chapter 1 is required to identify the infecting organism. These codes are
found in the following three categories:

• B95 – Streptococcus, staphylococcus, and enterococcus as the cause of diseases classified

elsewhere

• B96 – Other bacterial agents as the cause of diseases classified elsewhere

• B97 – Viral agents as the cause of diseases classified elsewhere

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Infections Resistant to Antibiotics
There are a growing number of pathogenic microorganisms that are resistant to some or all of
the drugs previously used to treat the resulting infections. All bacterial infections documented
as drug-resistant or antibiotic resistant must be identified. If a combination code is not
available to capture the drug resistance, a code from category Z16 Resistance to antimicrobial
drugs must be used following the infection code. Codes in category Z16 will be discussed in
more detail in Chapter 20.

Sepsis, Severe Sepsis, and Septic Shock

There are significant reporting guidelines for coding conditions that are documented as
urosepsis, septicemia, SIRS, sepsis, severe sepsis, and septic shock. The definitions of these
terms are sometimes used interchangeably; however, it should be remembered that for coding
purposes they are not considered synonymous. The current ICD-10-CM definitions and
terminology usage are explained below:

• Urosepsis:

– This term is nonspecific. There is no default code in the Alphabetic Index and it is not
to be considered as synonymous with sepsis. Any provider documenting a condition as
‘urosepsis’ must be queried for clarification before any code can be assigned.

• Septicemia:

– Although this term has traditionally been used to refer to a systemic disease associated
with the presence of pathogenic microorganisms (bacteria, viruses, fungi, or other
organisms) or their toxins in the blood, this term is not referenced in the Tabular List
of ICD-10-CM. The term ‘septicemia’ has been replaced with the term ‘sepsis.’ In the
Alphabetic Index, there is a cross-reference to ‘sepsis’ when the documentation supports
a diagnosis of sepsis. An unqualified diagnosis of septicemia is reported with A41.9
Sepsis, unspecified organism, which has the alternate term septicemia, NOS.

• Systemic Inflammatory Response Syndrome (SIRS):

– SIRS is not formerly defined in the ICD-10-CM guidelines. This term was formerly
defined as the systemic response to infection, trauma, burns, or other insult to the body,
such as cancer. Codes for SIRS are included in category R65. Symptoms and signs
specifically associated with a systemic inflammatory response, and code descriptors
containing the terminology systemic inflammatory response syndrome (SIRS) are used
only for SIRS of non-infectious origin (R65.10 and R65.11). Severe sepsis is the term

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 used in ICD-10-CM for SIRS due to an infectious process with acute organ
dysfunction. For SIRS of non-infectious origin with acute organ dysfunction (R65.11),
additional codes are required to identify the specific acute organ dysfunction.

• Sepsis:

– The term sepsis is not specifically defined in the guidelines, although it is generally
thought of as SIRS due to infection without acute organ dysfunction. Only one code
for sepsis, appropriate to the documented underlying systemic infection, is reported
such as A40.0 Sepsis due to streptococcus group A. If the causal organism is not
identified, code A41.9 Sepsis, unspecified organism is assigned.

– For sepsis due to a postprocedural infection, assign a code from T81.40-T81.43,

Infection following a procedure, or a code from O86.00-O86.03, Infection of obstetric
surgical wound, first to identify the site of the infection, if known. Assign an additional
code for sepsis following a procedure (T81.44), or sepsis following an obstetrical
procedure (O86.04) and an additional code to identify the infectious agent. If the
infection follows an infusion, transfusion, therapeutic injection, or immunization,
report a code from subcategory T80.2- or T88.0- first, followed by the code for the
specific infection.

• Severe Sepsis:

– Severe sepsis is not specifically defined in the ICD-10-CM guidelines. However,

guidance can be found in the list of alternate descriptions under the subcategory code
R65.2-. Severe sepsis includes: infection with associated acute organ dysfunction; sepsis
with acute organ dysfunction; sepsis with multiple organ dysfunction; SIRS due to
infectious process with acute organ dysfunction. A minimum of 2 codes are required—
the code for the underlying systemic infection must be reported first, followed by the
code for severe sepsis, which is further differentiated as being without septic shock
(R65.20) or with septic shock (R65.21). Codes from subcategory R65.2 can never be
assigned as principal diagnosis. Additional code(s) are required for identifying the
associated acute organ dysfunction.

– In cases where severe sepsis was not present on admission but developed during an
encounter, the underlying systemic infection and the appropriate code from subcategory
R65.2- should be assigned as secondary diagnoses.

– When sepsis or severe sepsis as well as a localized infection, such as pneumonia or

20
 cellulitis, are both reasons for admission, the code(s) for the underlying systemic
infection is assigned first and a code(s) for the localized infection is assigned
secondarily. When severe sepsis is present, the appropriate R65.2- code is also assigned
as a secondary diagnosis. If the localized infection is the reason for the admission, and
sepsis/severe sepsis develops later, the localized infection should be assigned first
followed by the appropriate sepsis/severe sepsis codes.

• Septic Shock:

– Septic shock is circulatory failure associated with severe sepsis, and therefore represents
a type of acute organ dysfunction. Two codes are required, the code for the underlying
systemic infection and the code for severe sepsis with septic shock (R65.21). The code
for septic shock cannot be assigned as the principal diagnosis. Additional codes for any
other acute organ dysfunction should also be assigned.

– If a postprocedural infection results in postprocedural septic shock, assign the codes

previously indicated for sepsis due to a postprocedural infection followed by code
T81.12- Postprocedural septic shock. Do not assign the code for severe sepsis (R65.21)
with septic shock. Use additional codes for any acute organ dysfunction.

Methicillin Resistant S. Aureus (MRSA) Conditions

Staphylococcus aureus is found on the skin and in the nasal cavities of 25-30% of the US
population. This is called colonization and healthy individuals with S. aureus colonization are
called carriers. In most healthy individuals colonization causes no major problems. However,
if the organisms get into the body through a cut or an open area, S. aureus can become a
serious or even life-threatening infection. If the S. aureus strain is resistant to most antibiotics
commonly used to treat staph infections, it is referred to as MRSA. MRSA is found on the
skin of approximately 1-2% of healthy individuals. MRSA infections are much more serious
and difficult to treat. Like other strains of staphylococcus, MRSA bacteria usually enter the
body through a broken area in the skin, although other entry sites include the respiratory
tract, surgical or other open wounds, intravenous catheters, and the urinary tract. While most
MRSA infections involve only the skin and present as a boil or small bump-like blemishes,
serious and often life-threatening infections also occur, including cellulitis, sepsis, and
pneumonia. Patients with compromised immune systems are at a significantly greater risk of
symptomatic secondary infection.

For coding purposes, S. aureus infections are classified as methicillin resistant, also referred to

21
as MRSA, or methicillin susceptible, also referred to as MSSA. Coding guidelines for
reporting S. aureus infections are as follows:

• Combination codes:

– There are combination codes for MRSA sepsis (A41.02) and MRSA pneumonia
(J15.212) and for MSSA sepsis (A41.01) and MSSA pneumonia (J15.211). A code
from subcategory Z16.11 Resistance to penicillins is not reported additionally for
MRSA sepsis or pneumonia because the combination code captures both the infectious
organism and the drug-resistant status.

• Other MRSA infections:

– Documentation of a current infection due to MRSA that is not covered by a

combination code, such as a wound infection, stitch abscess, or urinary tract infection is
reported with the code for the condition along with code B95.62, Methicillin resistant
Staphylococcus aureus (MRSA) infection as the cause of diseases classified elsewhere to
identify the drug resistant nature of the infection. A code from subcategory Z16.11
Resistance to penicillins is not reported additionally.

• MRSA or MSSA colonization:

– An individual person may be described as being colonized or a carrier of MSSA or

MRSA. Colonization means that MSSA or MRSA is present on or in the body
without necessarily causing illness. A positive colonization test may be documented as
“MRSA/MSSA screen positive” or “MRSA/MSSA nasal swab positive”.

– Documentation of MRSA or MSSA colonization without documentation of a disease

process due to MRSA or MSSA is reported with code Z22.322 Carrier or suspected
carrier of MRSA or Z22.321 Carrier or suspected carrier of MSSA.

• MRSA colonization and infection:

– For a patient documented as having both MRSA colonization and a current MRSA
infection during an admission, code Z22.322 Carrier or suspected carrier of Methicillin
resistant Staphylococcus aureus, and a code for the MRSA infection may both be
assigned.

Zika Virus Infections

• Code only confirmed cases:

– Only confirmed cases of zika virus as documented by the physician should be coded

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 with A92.5 Zika virus disease or P35.4 Congenital Zika virus disease. This is in
exception to the inpatient hospital guidelines. Confirmation does not require
documentation of the test performed; the physician’s diagnostic statement that the
condition is confirmed is sufficient.

– If the provider documents ‘suspected’, ‘possible’, or ‘probable’ zika, do not assign code
A92.5 or P35.4. Assign a code(s) for the reason for the encounter, such as fever, rash,
joint pain, or contact with and (suspected) exposure to Zika virus (Z20.821).

General Documentation Requirements

The general documentation requirements related to infectious and parasitic diseases are less
problematic than for many other chapters in ICD-10-CM. The main points to consider for
chapter 1 have been discussed in the chapter guidelines above: codes for localized infections
found within the respective body system chapters, specified terminology such as that related
to sepsis and severe sepsis, and the required use of combination codes, or an additional
identifying code when a combination code is not provided.

Code-Specific Documentation Requirements

In this section, some of the more frequently reported infectious and parasitic disease codes are
listed and the documentation requirements are identified. The focus is on frequently reported
conditions with specific clinical documentation requirements. Even though not all codes with
significant documentation requirements are discussed, this section will provide a
representative sample of the type of additional documentation that is required for infectious
and parasitic diseases.

Chlamydial Infection of Lower/Other Genitourinary Sites

Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United
States with many more cases unreported. Many people do not know they are infected because
symptoms can be mild or absent, with half of infected men and three quarters of infected
women having no symptoms at all. The bacteria can cause silent damage, particularly to
female reproductive organs, and infertility can result.

In ICD-10-CM, there is a combination code for the etiology of infection by Chlamydia

trachomatis and the manifestation (site).

Coding and Documentation Requirements

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Identify site:

• Lower genitourinary tract

– Bladder/urethra (cystitis, urethritis)

– Vulva/vagina (vulvovaginitis)

– Other specified lower genitourinary tract site (cervix, other sites)

– Unspecified lower genitourinary tract site

• Pelvis/peritoneum/other genitourinary organs

– Female pelvis/peritoneum (female pelvic inflammatory disease)

– Other specified site (epididymis/testis, other sites)

• Unspecified genitourinary site

ICD-10-CM Code/Documentation

A56.00 Chlamydial infection of lower genitourinary tract, unspecified

A56.01 Chlamydial cystitis and urethritis

A56.02 Chlamydial vulvovaginitis

A56.09 Other chlamydial infection lower genitourinary tract

A56.11 Chlamydial female pelvic inflammatory disease

A56.19 Other chlamydial genitourinary infection

A56.2 Chlamydial infection of genitourinary tract, unspecified

Documentation and Coding Example

Twenty-six-year-old female presents with intermittent fever, abdominal cramps, and low
back pain. She states she had UTI symptoms about a month ago with frequency and burning.
Symptoms resolved with fluids and cranberry juice but sexual intercourse has been
uncomfortable since then. Patient is married x 6 months, husband is her only sexual partner.
Current medications include oral contraceptives. On examination, this is a well-developed,
well-nourished young woman. Temperature 100.6, HR 88, RR 16, BP 100/60. PERRL,
ROM and pulses intact in upper extremities. Abdomen mildly tender to palpation in all
quadrants but no guarding, rebound tenderness or masses are present. Mild bilateral flank
tenderness is also present. Inguinal lymph nodes are slightly enlarged but non-tender to
palpation. Vulva and external genitalia normal. Speculum exam difficult to perform due to

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