Wiki Need additional Dx?

[kijoecker]

My coworker and I are a little confused on Dx 041.09. In her ICD-9 book there is an italicized note stating that you should report the disease first and then the bacteria. When I review in my ICD-9 book there is only the "note" that states "This category is provided to be used as an additional code to identify the bacterial agent in diseases classified elsewhere. This category will also be used to classify bacterial infections of unspecified nature or site." The problem is we only have the lab test that identifies Streptococcus infection and there is no documentation to indicate where the infection originated. Can diagnosis 041.09 be used with out listing a disease first?

Any clarification is appreciated.

Thank you

 

[rmwinder]

I think you are correct to use this category since the instructional note says this category will also be used to classify bacterial infections of unspecified nature or site. And that is indeed what you are dealing with. However, you didn't mention if your documentation noted a group of strep. Like group A, or B, or some other group that's not listed. If there is no group or classification listed, I'd go with 041.00.

You do not have to have another disease diagnosis. You can report the strep without anything else.

 

[mitchellde]

I respectfully disagree.. The category states "in diseases classifiable elsewhere" and the note is specific..
Note
This category is provided to be used as an additional code to identify the bacterial agent in diseases classified elsewhere. This category will also be used to classify bacterial infections of unspecified nature or site.
That does not mean you can report the code by itself it means you do not know the specific site or type of strep, but you do need an underlying condition. So query the provider. A coder is not to code from the lab report you must wait for the physician interpretation of the lab and it's significance.