Infections in ICD10

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Infections in ICD10 are coded somewhat inconsistently. There are #Diagnoses where the pathogen is implied and #Diagnoses where the pathogen must be coded separately. #Coding Antibiotic Resistance should also be done when there is one.

Dx_Date infections in Acquired Diagnosis / Complication

  • The date we want to use is the date in which the infection first appeared clinically. This can be a very difficult determination, and may include consideration of:
    • Date on which the clinical signs or symptoms first appeared (e.g. fever, or dysuria, etc)
    • Date on which the culture was sent --- but this can be misleading because a culture may not be sent until several days after the symptoms appear.
    • Thus, as usual, you must use your clinical judgment to decide when the infection first showed up.

Untreated positive cultures

  • Probably the most common of these is urine and sputum.
  • How to code these depends on what the clinical team thinks is true:
    • If they're not treating because they think it's NOT an infection and instead is colonization, then code it as one or the other of: Colonized with organism (not infected) and/or something like Urine tests, NOS, abnormal
    • If on the other hand, they just failed (permanently, or temporarily) to treat what became apparent later to be a real infection, then code it as an infection.

Coding when main dx may or may not be an infection

Our program requires infections to have a pathogen, and does not allow pathogens for non-infections. Many of our "wastebasket" NOS codes could be used for infections and non-infections. In order to be able to code an infection with one of these, you must also code Infectious disease NOS and the Pathogen as Combined ICD10 codes.

Coding when the pathogen isn't clear (yet)

See Lab and culture reports for where to find pathogen info.

If you don't get a presumptive pathogen and it's not a situation which relates to Infection with implied pathogen, you should then use Infectious organism, unknown.

Other related information

Cross Checks

Data Integrity Checks (automatic list)

Query check ICD10 Inf Potential Infection must have pathogen or altCCMDB.accdbdeclined
Check Inf Antibiotic resistance must have pathogen or Infection with implied pathogenCCMDB.accdbimplemented
Check Inf Infection with implied pathogen must not have a pathogen combined codeCCMDB.accdbimplemented
Query check ICD10 Inf Infection req Pathogen must have oneCCMDB.accdbimplemented
Query Check Inf Pathogens must have Infection requiring pathogen or Potential InfectionCCMDB.accdbimplemented

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