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Infectious and Parasitic Diseases
Appendix C – contains information to help with
diseases in these chapters
Multiple coding often necessary
Identify:
Body Site
Severity of the disease
Specific organism
Etiology of infection
Associated signs, symptoms, manifestation
Infectious diseases
Examples: TB, HIV, Septicemia
Late Effects: identifies the underlying cause
of a condition currently present in the
patient
Example: Mental retardation due to old
viral encephalitis
319 Unspecified Mental retardation
139.0 Late effects of viral encephalitis
HIV Classification
Code only confirmed cases of HIV
infection/illness; records with statements
of “suspected”, “likely”, “possible”, or
“questionable” are to be returned to the
physician for clarification
Codes: 042,V08, and 795.71 are used
together to code positive HIV diagnoses.
Neoplasms

Neoplasm behavior:
Malignant
Primary
Secondary
In Situ
Benign
Uncertain behavior
Unspecified nature
Morphology codes (M)
Explain the histology and behavior of a
neoplasm
 Four digits with a fifth separated by a
forward slash (M8140/3)
 The fifth digit is the behavior code

 /0 benign /1 uncertain/borderline
/2 in situ/
intraepithelial/noninvasive/noninfiltrating
/3 malignant/primary
/6 malignant -2ndary or metastatic
/9 malignant, uncertain if primary or
metastatic
V Codes
Records chemotherapy, radiation therapy,
follow-up visits, family history of cancer,
history of primary malignancy
 Designates the malignancy as the principal
diagnosis, EXCEPT: when the admission
or encounter is SOLELY for
administration of chemotherapy,
immunotherapy, or radiation therapy
 When exception: V code is principal
diagnosis code, malignancy is additional
diagnosis

Coding Neoplasms
By system
 By site (anatomical, Primary)
 Type (previous slide)
 Asterisk – when it follows the term of
location, that code cannot be used, must
be more specific
 Metastatic from – primary is the site the
new growth is ‘from’

Metabolic/Immunity Disorders

Diabetes: with or without meds, types,
lead to other illnesses

Gout: acute, chronic, with other illnesses

Imbalances: Too much or not enough fluid,
acid levels, etc.
Blood/Organs
Anemia: Types, side effects, cause
 Clotting: Where, cause, complications, due
to
 White blood cells: Diseases, usually need
4th and 5th digits
 Blood forming organs: Tissue damage,
organ shut down or transplant

Mental Disorders

Sections:
Psychoses
Neurotic Disorders, Personality Disorders,
other Nonpsychotic mental disorders
Mental Retardation
Fifth digits occur frequently in mental
disorder diagnoses

Categories:
Axis I: All psychiatric except personality and
mental retardation
Axis II: Personality disorders and mental
retardation
Axis III: IDs the presence of general medical
conditions
Axis IV: Note clinically relevant psychosocial
and environmental problems
Axis V: Indicates the individual’s overall
psychological, social and occupational
functioning
Axes I, II, and III provide diagnostic information
Alcohol and Drugs
Alcoholism: chronic mental condition
coded under Alcohol dependence
syndrome – several forms
 Drug dependence: chronic mental and
physical condition coded under drug
addiction – several stages
 Fifth digits for alcohol/drug dependence
and abuse:

• 0 Unspecified 1 Continuous
• 2 Episodic
3 Remission
Therapy for Dependence
Detoxification
 Rehabilitation
 Coding therapies:

•
•
•
•
•
Tabular List
94.61 Alcohol rehabilitation (94.64 drug re)
94.62 Alcohol detoxification (94.65 drug de)
94.63 Alcohol rehab and detox (94.66 drug)
There are codes for combinations of alcohol
and drug dependence