Infectious Diseases

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Infectious Diseases

General Documentation Considerations

Diagnoses

ICD-9 to ICD-10 Crosswalk

The codes in these crosswalks were selected based on the most commonly used ICD-9 codes according to historical MedStar Health coding data and from professional coding associations, and are ordered by frequency of use. 

Not all the codes you need are contained in this list. For a comprehensive list of ICD-10 codes, use Diagnosis Assistant or the IMO Anywhere tool.

Code Description (ICD-9 codes are in blue)
042 Human immunodeficiency virus (HIV) disease
B20 Human immunodeficiency virus (HIV) disease
780.60 Fever, unspecified
R50.2 Drug induced Fever
R50.1 Fever, unspecified
790.7 Bacteremia
R78.81 Bacteremia
486 Pneumonia organism unspecified

If pneumonia is viral, and virus known:
J12.0 Adenoviral pneumonia
J12.1
Respiratory syncytial virus pneumonia
J12.81
Pneumonia due to SARS-associated coronavirus
J12.89
Other viral pneumonia
J12.9
Viral pneumonia, unspecified

Detailed diagnosis choices are available if the organism has been identified
J13
Pneumonia due to Streptococcus pneumonia
J14
Pneumonia due to Hemophilus influenzae
J15.0
Pneumonia due to Klebsiella pneumoniae
J15.1
Pneumonia due to Pseudomonas
J15.6
Pneumonia due to other aerobic Gram-negative bacteria
J15.7
Pneumonia due to Mycoplasma pneumonia
J15.9
Unspecified bacterial pneumonia due to gram positive cocci
J15.0
Chlamydial pneumonia
288.60 Leukocytosis, unspecified
D72.89 Other specified disorders of white blood cells
D72.820 Lymphocytosis (symptomatic)
D72.823
Leukemoid reaction
D72.824
Basophilia
D72.828
Other elevated white blood cell count
D72.829
Elevated white blood cell count, unspecified
070.54 Chronic hepatitis C without hepatic coma
B18.2 Chronic hepatitis C without hepatic coma
599.0 Urinary tract infection site not specified
N39.0 Urinary tract infection site not specified
518.81 Acute respiratory failure

Documentation must differentiate between acute and regular respiratory failure and also whether there is hypoxia or hypercapnia: Specific diagnosis options:
J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J96.01
Acute respiratory failure with hypoxia
J96.02
Acute respiratory failure with hypercapnia
J96.91
Respiratory failure, unspecified with hypoxia
J96.92
Respiratory failure, unspecified with hypercapnia
J96.00
Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
038.9 Unspecified septicemia

Separate Codes for sepsis and organism causing sepsis have been combined into one code under ICD-10. Specific examples include:
A40.0 Sepsis due to streptococcus, group A
A40.1
Sepsis due to streptococcus, group B
A40.3
Sepsis due to Streptococcus pneumoniae
A40.8
Other streptococcal sepsis
A40.9
Streptococcal sepsis, unspecified
A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.02
Sepsis due to Methicillin resistant Staphylococcus aureus
A41.1
Sepsis due to other specified staphylococcus
A41.2
Sepsis due to unspecified staphylococcus
A41.3
Sepsis due to Hemophilus influenzae
A41.4
Sepsis due to anaerobes
A41.51
Sepsis due to Escherichia coli [E. coli]
A41.52
Sepsis due to Pseudomonas
A41.53
Sepsis due to Serratia
A41.59
Other Gram-negative sepsis
A41.81
Sepsis due to Enterococcus
786.50 Chest pain, unspecified
R07.1 Chest pain on breathing
R07.2 Precordial pain
R07.81
Pleurodynia
R07.82
Intercostal pain
R07.89
Other chest pain
V70.0 Routine general medical examination at a health care facility
Z00.00 Encounter for general adult medical examination without abnormal findings
Z00.01 Encounter for general adult medical examination with abnormal findings
682.9 Cellulitis and abscess of unspecified sites
L03.90 Cellulitis, unspecified
L03.91 Acute lymphangitis, unspecified
L02.91
Cutaneous abscess, unspecified
L98.3
Eosinophilic cellulitis [Wells]
892.0 Open wound of foot except toe(s) alone without complication

Document if open wound or laceration of foot with or without foreign body. Note if bite. Specify laterality. ICD-10 options include the following:
S91.301A Unspecified open wound, unspecified foot, initial encounter
S91.302A
Unspecified open wound, right foot, initial encounter
S91.311A
Unspecified open wound, left foot, initial encounter
S91.312A
Laceration without foreign body, right foot, initial encounter
S91.319A
Laceration without foreign body, left foot, initial encounter
S91.331A
Laceration without foreign body, unspecified foot, initial encounter
S91.332A
Puncture wound without foreign body, right foot, initial encounter
S91.339A
Puncture wound without foreign body, left foot, initial encounter
S91.351A
Puncture wound without foreign body, unspecified foot, initial encounter
S91.352A
Open bite, right foot, initial encounter
S91.359A
Open bite, left foot, initial encounter

Open bite, unspecified foot, initial encounter
401.9 Unspecified essential hypertension

Specific types of hypertension should be noted. ICD-10 options include:
I15.1 Hypertension secondary to other renal disorders
I15.2
Hypertension secondary to endocrine disorders
I15.0
Renovascular hypertension
O10 Pre-existing hypertension complicating pregnancy, childbirth and the puerperium
O11 Pre-existing hypertension with pre-eclampsia
I10
Essential (primary) hypertension
I15.9
Secondary hypertension, unspecified
I97.3
Postprocedural hypertension
K76.6 Portal hypertension
567.22 Peritoneal abscess
K65.1 Peritoneal abscess
998.32 Disruption of external operation (surgical) wound
T81.31XA Disruption of external operation (surgical) wound
250.00 Diabetes mellitus without mention of complication, type II
or unspecified type, not stated as uncontrolled

Document type 2 diabetes with or without complications and note if controlled or uncontrolled.
E11.9 Type 2 diabetes mellitus without complications
E13.9
Other specified diabetes mellitus without complications
787.91 Diarrhea

Allergic and dietetic gastroenteritis can now be reported under one code under ICD-10. See available code choices below:
K52.2 Allergic and dietetic gastroenteritis and colitis
K52.89
Other specified noninfective gastroenteritis and colitis
R19.7 Diarrhea, unspecified
041.11 Methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site

Document if Staphylococcus infection is the cause of another known condition or disease.
B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere
A49.01 Methicillin susceptible Staphylococcus aureus infection, unspecified site
996.61 Infection and inflammatory reaction due to cardiac device implant and graft

Document if infection and inflammatory reation is due to other cardiac valve prosthesis, devices, implants, or grafts.
T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter
T82.7XXA
Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
707.10 Unspecified ulcer of lower limb

Document if pressure chronic ulcer is with breakdown of skin, exposed fat layer, or necrosis. Note laterality and specific region of limb.
L97.909 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity
L97.901
Non-pressure chronic ulcer of unspecified part of unspecified lower leg limited to breakdown of skin
L97.902
Non-pressure chronic ulcer of unspecified part of unspecified lower leg with fat layer exposed
L97.903
Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of muscle
L97.904
Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of bone
L97.911
Non-pressure chronic ulcer of unspecified part of right lower leg limited to breakdown of skin
L97.912
Non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed
L97.913
Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of muscle
L97.914
Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of bone
L97.919
Non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity
L97.921
Non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin
L97.922
Non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed
L97.923
Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of muscle
L97.994
Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of bone
L97.929
Non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity
998.59 Other postoperative infection

Important to note if postprocedural retroperitoneal abscess or infection following a procedure.
K68.11 Postprocedural retroperitoneal abscess
T81.4XXA Infection following a procedure, initial encounter
730.20 Unspecified osteomyelitis site unspecified

No longer need to document site of osteomyelitis. ICD-10 maps to unspecified site for all locations:
M86.9 Osteomyelitis, unspecified
780.97 Altered mental status

Documentation should detail if altered mental status or disorientation
R41.0 Disorientation, unspecified
R41.82
Altered mental status, unspecified
996.62 Due to vascular device, implant and graft
T82.7XXA Due to vascular device, implant and graft
585.6 End stage renal disease
N18.6 End stage renal disease
996.66 Infection and inflammatory reaction due to internal joint prosthesis

Document the site of prosthesis causing infection. Note laterality when possible. A sample of available codes is below.
T84.51XA Infection and inflammatory reaction due to internal right hip prosthesis, initial encounter
T84.52XA
Infection and inflammatory reaction due to internal left hip prosthesis, initial encounter
T84.53XA
Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter
T84.54XA
Infection and inflammatory reaction due to internal left knee prosthesis, initial encounter
995.90 Systemic inflammatory response syndrome unspecified

Document if with or without acute organ dysfunction.
R65.10 Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction
785.51 Cardiogenic shock
R57.0 Cardiogenic shock
322.9 Meningitis unspecified
G03.0 Nonpyogenic meningitis
G03.8 Meningitis due to other specified causes
G03.1
Chronic meningitis
G03.9
Meningitis, unspecified
795.52 Nonspecific reaction to cell mediated immunity measurement of gamma interferon antigen response without active tuberculosis
R76.12 Nonspecific reaction to cell mediated immunity measurement of gamma interferon antigen response without active tuberculosis
041.12
Methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site

Document if Methicillin resistent Staphylococcus aureus infection is the cause of an additional disease.
A49.02 Methicillin resistant Staphylococcus aureus infection, unspecified site
B95.62
Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere
272.4 Other and unspecified hyperlipidemia
E78.2 Mixed hyperlipidemia
E78.3 Hyperchylomicronemia
E78.4
Other hyperlipidemia
E78.5
Hyperlipidemia, unspecified
789.00 Abdominal pain, unspecified site

ICD-10 will require the site of pain be documented if available and the type of pain (i.e. epigastric, periubilical, etc.)
It is important to also note the site or nature of abdominal pain if available.
R10.11 Right upper quadrant pain
R10.12
Left upper quadrant pain
R10.31
Right lower quadrant pain
R10.32
Left lower quadrant pain
R10.33
Periumbilical pain
R10.13
Epigastric pain
R10.84
Generalized abdominal pain
R10.10
Upper abdominal pain, unspecified
R10.2
Pelvic and perineal pain
R10.30
Lower abdominal pain, unspecified
R10.9
Unspecified abdominal pain
R10.0
Acute abdomen
V05.3 Need for prophylactic vaccination and inoculation against viralhepatitis
Z23 Encounter for immunization
786.09 Respiratory abnormalities not otherwise classified

Documentation should specify type of airway abnormaliites. Specific codes now exist for periodic breathing and snoring:
R06.3 Periodic breathing
R06.83
Snoring
R06.89
Other abnormalities of breathing
R06.00
Dyspnea, unspecified
R06.09
Other forms of dyspnea
567.9 Unspecified peritonitis

Document the nature of peritonitis if known. ICD-10 options include the following:
K65.9 Peritonitis, unspecified
K65.8
Other peritonitis
K65.3
Choleperitonitis
K68.9
Other disorders of retroperitoneum
511.9 Unspecified pleural effusion

It is important to document the type of effusion if possible in ICD-10.
J90 Pleural effusion, not elsewhere classified
J94.2
Hemothorax
J94.8
Other specified pleural conditions
J94.0
Chylous effusion
J91.0
Malignant pleural effusion
J91.8
Pleural effusion in other conditions classified elsewhere
518.53 Acute and chronic respiratory failure following trauma and surgery

Document if acute and chronic respiratory failure with or without hypoxia or hypercapnia. Note if postprocedural.
J95.822 Acute and chronic postprocedural respiratory failure
J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.21 Acute and chronic respiratory failure with hypoxia
J96.22 Acute and chronic respiratory failure with hypercapnia
008.45 Intestinal infection due to clostridium difficile
A04.7 Enterocolitis due to Clostridium difficile