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June 18, 2012

Coding for STDs
For The Record
Vol. 24 No. 12 P. 27

Sexually transmitted diseases (STDs) are passed through infected bodily fluids exchanged during sexual contact or nonsexually, such as from mother to infant during pregnancy or childbirth. STDs may also be documented as sexually transmitted infections (STIs). There are more than 20 types of STDs caused by bacteria, viruses, or parasites. This column focuses on the more common STDs.

Gonorrhea is a bacterial infection that can affect the urethra, rectum, or throat but most commonly appears in the genital tract. If symptoms do appear, in men, they include painful urination, puslike discharge from the penis, and pain or swelling in one testicle. In women, they may include increased vaginal discharge, painful urination, vaginal bleeding between periods, and abdominal or pelvic pain. Gonorrhea is classified to ICD-9-CM category 098. Fourth and fifth digits are required to identify the acuity and the body site affected.

Syphilis is a bacterial infection that originates with a painless sore on the genitals, rectum, or mouth. After the initial infection, the bacteria may lie dormant in the body for a period of time before reactivating. Early syphilis is easily treatable with penicillin. However, if it advances, syphilis can severely damage the heart, brain, or other organs and become life threatening. Syphilis is assigned to categories 090 to 097. The specific code assignment will depend on the stage or type of syphilis, such as the following:

• Primary syphilis (091.0 to 091.2): This may present with a chancre at the site where the bacteria entered the body. The chancre usually appears three weeks after exposure but is usually painless and therefore goes unnoticed. The chancre will heal within six weeks.

• Secondary syphilis (091.3 to 091.9): After the original chancre heals, a rash may appear on the trunk before spreading over the entire body.

• Latent syphilis: This occurs when the syphilis is not treated and the symptoms are hidden. Code 096 is assigned for syphilis without clinical manifestations, with positive serological reaction and negative spinal fluid test, two years or more after infection. Code 097.1 is assigned for latent syphilis, unspecified or when there is a positive serological reaction for syphilis.

• Tertiary or late syphilis: This occurs when the syphilis is not treated in the early stages and complications develop. The code assignment depends on the body system affected or the specific complication, such as central nervous system (category 094), cardiovascular (category 093), or other forms of late syphilis (category 095).

• Congenital syphilis (category 090): This is when a baby is infected through the placenta or during childbirth.

According to the Centers for Disease Control and Prevention, genital human papillomavirus (HPV) is the most common STI. There are more than 40 types that can infect the genital areas, mouth, and throat. An infection caused by HPV may include genital warts, warts in the throat, and cancer of the cervix, vulva, vagina, penis, anus, or oropharynx.

Code 079.4 is assigned as an additional code for an HPV infection. First code the specific infection, if known.

Genital herpes is caused by the herpes simplex virus (HSV) and may cause pain, itching, and sores in the genital area. However, a person infected with HSV may not experience any symptoms. After the initial infection, the virus remains dormant but can reactivate several times per year.

Genital herpes is highly contagious regardless of visible sores. It is classified to subcategory 054.1. A fifth-digit subclassification is required to identify the specific location, such as the following:

• 054.10, Genital herpes, unspecified;

• 054.11, Herpetic vulvovaginitis;

• 054.12, Herpetic ulceration of vulva;

• 054.13, Herpectic infection of penis; and

• 054.19, Other.

HIV, the virus that causes AIDS, can be present in bodily fluids such as blood, semen, vaginal secretions, breast milk, and saliva. Being HIV positive is not the same as having AIDS (code 042). Many patients test positive for HIV but don’t become sick for many years. If the patient is HIV positive but also asymptomatic and has not been diagnosed previously with an HIV-related illness, assign code V08, Asymptomatic human immunodeficiency virus infection status. “Do not use [code V08] 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 042 in these cases” (AHA Coding Clinic for ICD-9-CM, 2006, fourth quarter, page 153). Use code 795.71, Nonspecific serologic evidence of human immunodeficiency virus, for patients with inconclusive or nonspecific HIV tests.

Only confirmed cases of AIDS or HIV infection should be coded. Do not assign a code for the HIV infection if it is documented as possible, suspected, etc. This is an exception to the coding guideline that states conditions may be coded in the inpatient setting if documented as possible, probable, or suspected.

Coding and sequencing for STDs 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 Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.


ICD-10-CM Coding for AIDS
Coding for AIDS in ICD-10-CM is similar to ICD-9-CM in that it differs only in the code used (B20). Coding guidelines remain the same. Code B20, Human immunodeficiency virus disease, includes AIDS, AIDS-related complex, and HIV infection, symptomatic.

There are also the following coding directives:

• Code first HIV disease complicating pregnancy, childbirth and the puerperium, if applicable (O98.7-).

• Use additional code(s) to identify all manifestations of HIV infection.

• Excludes 1: Asymptomatic human immunodeficiency virus infection status (Z21), Exposure to HIV virus (Z20.6), and Inconclusive serologic evidence of HIV (R75).