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For other articles and previous issues click here. August 1, 2005 Coding for
Bacterial Infections Bacteria are single-celled microorganisms shaped like rods, spheres, or spirals that are seen only through a microscope. They are self-sufficient and reproduce by dividing, but not all bacteria are harmful. An infection occurs when harmful bacteria or another infectious agent enters the body and begins to multiply. A disease occurs when the infection causes damage to cells in the body and signs and symptoms appear. AHA Coding Clinic for ICD-9-CM category 041 is for bacterial infection in conditions classified elsewhere and of unspecified site. This category of codes is intended to be used as an additional or secondary code to identify the bacterial agent in diseases classified elsewhere and is not ordinarily sequenced as principal diagnosis. The disease caused by the bacteria (eg, urinary tract infection [UTI]) should be sequenced first. A code from category 041 can be used alone, if necessary, to classify bacterial infections of unspecified nature or site. In the rare circumstance that the physician documents bacterial infection as the principal diagnosis with no underlying condition and the clinical situation, therapy provided, and response to therapy support the physician’s clinical judgment, a code from category 041 may be sequenced as principal diagnosis (AHA Coding Clinic for ICD-9-CM, 1991, second quarter, page 9). Category 041 includes the following fourth-digit subcategories: • 041.0, Streptococcus — a fifth-digit subclassification is needed to identify the specific type of streptococcus • 041.1, Staphylococcus — a fifth-digit subclassification is needed to identify the specific type of staphylococcus • 041.2, Pneumococcus • 041.3, Friedlander’s bacillus — includes infection by Klebsiella pneumoniae • 041.4, Escherichia Coli (E. Coli) • 041.5, Hemophilus influenzae (H. Influenzae) • 041.6, Proteus (mirabilis) (morganii) • 041.7, Pseudomonas • 041.81, Mycoplasma — includes Eaton’s agent and pleuropneumonia-like organisms • 041.82, Bacteroides fragilis • 041.83, Clostridium perfringens • 041.84, Other anaerobes — includes gram-negative anaerobes • 041.85, Other gram-negative organisms —
including aerobacter aerogenes, gram- • 041.86, Helicobacter pylori (H. pylori) • 041.89, Other specified bacteria • 041.9, Bacterial infection, unspecified If the code for a condition completely classifies the underlying condition and the organism, then a code from category 041 is not necessary. For example, septicemia due to staphylococcus aureus is completely identified with code 038.11. Assigning code 041.11 would not provide any additional information. However, if the code does not identify the organism that has been documented in the medical record, then it would be appropriate to sequence a code from category 041 as a secondary diagnosis. For example, newborn sepsis is classified to code 771.81. Since code 771.81 does not identify the organism involved, then it would be appropriate to assign a code from category 041 as a secondary diagnosis with code 771.81 (AHA Coding Clinic for ICD-9-CM, 2005, first quarter, page 63). Other Infectious Agents • Virus — smaller than bacteria and needs a suitable host to reproduce. The specific code for a viral infection will depend on the condition caused by the virus (eg, AIDS). If viral infection is documented, but the documentation does not include the specific virus or condition caused by the virus, then assign code 079.99. • Fungi — includes molds, yeast, mushrooms which can be found in air, water, soil, and plants. The specific code assignment will depend on the condition caused by the fungal infection. Candidiasis is classified to category 112. If a UTI is caused by candidiasis, assign code 112.2. However, if the UTI is caused by a noncandidal yeast infection, assign code 117.9 (AHA Coding Clinic for ICD-9-CM, 1995, second quarter, page 7). • Protozoa — lives in the body as a parasite. Protozoal intestinal diseases are classified to category 007. • Helminths are also parasites and include conditions such as tapeworm infestation (123.x) and roundworm infection (127.0). Helminthiases are classified to category range 120-129. Coding and sequencing for bacterial infections are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding. — This information was prepared by Audrey Howard, RHIA, of 3M Health Information Systems (800-367-2447), a supplier of coding and classification systems to more than 5,000 customers worldwide. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information. |
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