Documentation Dissection - AAPC

Documentation Dissection Operative Report Preoperative Diagnoses: Splenic abscess and multiple intra-abdominal abscess, related to HIV, AIDS, and hepatitis C. Postoperative Diagnoses: Splenic abscess and multiple intra-abdominal abscess, related to HIV |1|, AIDS |2|, and hepatitis C |3|. Operative Procedure: 1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses. 2. Splenectomy. 3. Vac Pak closure. _____. |1| Diagnosis related to HIV results in AIDS (B20) being reported as the primary diagnosis. |2| The patient has AIDS. |3| Hepatitis C is relevant because it may have an impact on the patient's treatment and recovery. _____. What ICD-10-CM diagnosis/es code(s) is/are reported? ICD-10-CM Codes: B20, , , Rationale: The patient is diagnosed with abscesses on the spleen and intra-abdominal cavity (related to his HIV), AIDS and hepatitis C. According to Official coding Guidelines , if a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, followed by additional diagnosis codes for all reported HIV-related conditions.

hepatitis C. According to Official Coding Guidelines 1.C.1.a.2., if a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, followed by additional diagnosis codes for all reported HIV-related conditions. In the Index to Diseases and Injuries, look for AIDS; you are referred to B20.

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  Coding, Documentation, Dissection, Documentation dissection

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