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Acquired Immune Deficiency Syndrome (AIDS)

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The late stage of HIV infection, when a person's immune system is severely damaged and has difficulty fighting diseases and certain cancers.

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acute posthemorrhagic anemia

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Anemia due to acute blood loss. Reported with code D62.

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anemia

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Defined as a decrease in the number of erythrocytes (red blood cells), the quantity of hemoglobin, or the volume of packed red cells in the blood.

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aplastic anemia

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A condition in which the bone marrow is damaged. As a result, the stem cells are destroyed or develop abnormally.

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aspiration

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Taking or letting out fluids or gases from a body part. (also referred to as 'drainage').

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bandemia

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The presence of an excess number of immature WBCs or band cells, while the total WBC count is normal.

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benign

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(of a disease) not harmful in effect: in particular, (of a tumor) not malignant. growth does not invade adjacent structures or spread to distant sites but may displace or exert pressure on adjacent structures

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biopsy

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A procedure that may also be described as an aspiration or simply an aspiration.

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carcinoma in situ (CIS)

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Carcinoma in the stage of development when the cancer cells are still within their site of origin (as the mouth or uterine cervix).

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coagulation defects

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Disorders of the platelets that result in serious bleeding due to a deficiency of one or more clotting factors.

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combination codes

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One code that describes both the etiology and manifestation of the disease, such as streptococcal pharyngitis, ICD-10-CM code J02.0 The underlying disease is the streptococcal infection and the manifestation is the pharyngitis.

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hemolytic anemia

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A condition in which your bone marrow cannot make enough new RBCs to replace the ones that are destroyed too early.

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hemolytic anemia - acquired

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Caused by extrinsic factors such as drugs or toxins, systemic diseases, liver or renal failure, or abnormal immune responses.

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hemolytic anemia - hereditary

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Related to problems with the genes that control how the RBCs are made in the body.

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heparin-induced thrombocytopenia (HIT)

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A life-threatening clinical event that can occur in 3 to 5 percent of all patients receiving unfractionated heparin for at least 5 days or in about 0.5 percent of patients receiving low molecular-weight heparin.

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histology

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The study of cell structures under a microscope.

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Human Immunodeficiency Virus (HIV)

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A virus which can lead to acquired immune deficiency syndrome (AIDS). There are 2 types of HIV = HIV-1 and HIV-2.

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laterality

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Right or left side.

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malignant

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Tending to produce death or deterioration ; especially : tending to infiltrate, metastasize, and terminate fatally

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malignant primary

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A primary neoplasm is the site where a neoplasm originated.

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malignant secondary

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A secondary neoplasm...may be described as a metastatic site.

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metastasis

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The movement or spreading of cancer cells from one organ or tissue to another.

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Methicillin Resistant Staphylococcus aureaus (MRSA)

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A staph germ that is not cured with the typical antibiotics that usually cures staphylococcus infections.

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Methicillin susceptible Staphylococcus aureaus (MSSA)

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Identifies that an organism can be treated with methcillian antiobiotics.

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morphology

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Used to describe neoplasms. The form and structure of the tumor in the organ.

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neoplasm

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Any new or abnormal growth of body tissue.

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neutropenia

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A decrease in the number of neutrophils, a type of white blood cell.

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overlapping lesion

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A primary malignant neoplasm that overlaps two or more sites.

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pernicious anemia

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A form of vitamin B12 deficiency because of the body's inability to absorb vitamin B12 and make sufficient number of RBCs.

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primary site

answer

Origin of the tumor.

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residual condition

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A condition which certain infectious and parasitic diseases leave long-lasting effects after the infection is cured.

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secondary site

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May be referred to as a metastatic site in the record documentation.

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sepsis

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A serious medical condition caused by the body's immune response to an infection.

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sepsis shock

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A serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure.

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severe sepsis

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An infection with associated acute organ dysfunction.

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sickle-cell disorder

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A condition in which the body makes abnormal hemoglobin that causes red blood cells (RBCs) to have a sickle, or a "C" shape.

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thalassemia

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Inherited blood disorders, passed from parents to children through genes.

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thrombocytopenia

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Diagnosed when the platelets fall below 100,000/mm. Two types of thrombocytopenia are recognized...primary or idiopathic and secondary.

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topography

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A description of a region or a special part of the body.

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transplantation

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To physically take a place or a function of all or a portion of a similar body part.

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uncertain behavior

answer

Neoplasms of unspecified behavior are tumors that a pathologist cannot determine as being either benign or malignant because some features of each are present.

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unspecified behavior

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Neoplasms of unspecified behavior include tumors in which neither the behavior nor the histological type is specified in the diagnosis.

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Von Willebrand disease (vWD)

answer

A bleeding disorder that affects the blood's ability to clot.

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B37.81

answer

Candidal esophagitis

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A04.7, Z16.35

answer

Clostridium difficile (c. diff) colitis. This organism was resistant to multiple antimicrobial drugs

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A02.9

answer

Acute bacterial food poisoning due to Salmonella

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N39.0, B96.20

answer

Urinary tract infection due to E. coli bacteria

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B20, B59

answer

Pneumocystis pneumonia due to AIDS

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A41.51

answer

E. Coli sepsis

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A56.11

answer

Pelvic inflammatory disease as the result of sexually transmitted dChlamydia

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A39.2, R65.21

answer

Septic shock due to acute meningococcal severe sepsis

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B18.1

answer

Chronic viral hepatitis, type B

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A41.50, R65.20, J96.00

answer

Gram-negative severe sepsis with acute respiratory failure

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C43.4

answer

Malignant melanoma of the skin of the scalp

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D22.61

answer

Benign melanoma of the skin of the right shoulder

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C71.3

answer

Glioma of the parietal lobe of brain

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C61

answer

Adenocarcinoma of prostate

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D17.0

answer

Lipoma of face

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D13.7, E16.1

answer

Hypoglycemia due to islet adenoma pancreas

question

C15.4

answer

Epidermoid carcinoma of the middle third of the esophagus

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D35.2, N64.3

answer

Galactorrhea due to pituitary adenoma

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D35.02, E26.01

answer

Adenoma of the left adrenal cortex with Conn's syndrome

question

D02.0

answer

Carcinoma in situ of vocal cord

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C34.31, C77.1, C77.7, C79.51

answer

Small cell carcinoma of the right lower lobe of the lung with metastasis to the intrathoracic lymph nodes, brain and right rib

question

C45.0

answer

Malignant mesothelioma of pleura

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C93.91

answer

Subacute monocutic leukemia in remission

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C43.52, C43.62

answer

Melanoma of the left breast and left arm

question

D3A.021

answer

Benign carcinoid of the cecum

question

C79.31, Z85.3, Z90.12

answer

Patient had left breast carcinoma four years ago and a left mastectomy was performed. She has been well since that time with no further treatments except for yearly checkups. The patient is now being seen with visual disturbances, dizziness, headaches and blurred vision. Workup was completed which revealed metastasis to the brain, accounting for these symptoms. This was identified as being metastatic from the breast, not a new primary

question

Z51.11, C17.8, Z90.49

answer

The reason for the encounter is to receive chemotherapy following the recent diagnosis of carcinoma of the small intestines. The tumor was in the area where the duodenum and jejunum join. The cancer was resected two months ago and the patient has been receiving chemotherapy

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C25.0, C78.01

answer

Carcinoma of the head of the pancreas with metastasis to the right lung

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C7A.093

answer

Malignant carcinoid tumor of the kidney

question

E86.0, G89.3, C50.111, C79.31, C78.7

answer

Terminal carcinoma of the central portion of the right breast, metastatic to the liver and brain, was seen for dehydration and chronic intractable neoplasm-related pain. The patient was rehydrated with IVs and given IV pain medication with no treatment directed toward the carcinoma

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HIV infection

answer

Code only confirmed cases, rules for sequencing

question

Infections resistant to antibiotics

answer

Use of category Z16

question

Infectious agents as the cause of diseases classified to other chapters

answer

Use of categories B95, B96, B97

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AIDS code B20

answer

followed by additional codes for all reported HIV-related conditions

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Asymptomatic HIV

answer

infection status code Z21

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Patients with inconclusive laboratory evidence of HIV

answer

code R75

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Sequelae

answer

Sequelae are conditions that were produced by another condition that itself is no longer present

question

Sequelae

answer

are not the same as "chronic" infections

question

Code chronic current infections

answer

to active infectious disease

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Uncertain behavior

answer

tumors that cannot be determined to be either benign or malignant because some features of each are present pathologically

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Unspecified behavior

answer

neither the behavior or histological type is specified in the diagnosis

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Benign neoplasms

answer

tumor growth does not invade adjacent structures or spread to distant sites

question

In situ

answer

malignant changes in cells but surrounding tissue has not been invaded

question

Malignant Neoplasms

answer

Can invade and destroy adjacent structures as well as spread to distant sites

question

Morphology type

answer

Leukemia Melanoma Adenocarcinoma

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Behavior

answer

Malignant Benign

question

Alphabetic Index entries for specific terms

answer

Leukemia Lymphoma Multiple myeloma

question

Alphabetic Index used for other types of malignancies,

answer

such as lymphatic, hematopoietic, and other neoplasms

question

Lymphatic and hematopoietic tissue

answer

Considered systemic and do not metastasize

question

Squamous cell or epidermoid carcinoma

answer

should be coded as malignant neoplasm of skin

question

"Metastatic to" a site and "direct extension to"

answer

The "metastatic to" site stated is a secondary site Example: Metastatic carcinoma of the colon to the lung Primary site is colon Secondary site is lung

question

Papilloma of any type should be coded

answer

as benign neoplasm of the skin

question

"Spread to" or "extension to"

answer

Diagnoses should be coded as primary sites with metastases Example: Adenocarcinoma of the stomach with spread to the peritoneum Primary site is stomach Secondary site is peritoneum

question

Patient may have multiple secondary sites

answer

Each site is coded

question

Medical term "malignant" has two meanings

answer

Resistant to treatment, occurring in severe form and frequently fatal; tending to become worse and leading to an ingravescent (increasing in severity) course Related to a neoplasm, means having the property of locally invasive and destructive growth and metastasis

question

Effusion is the

answer

escape of fluid from blood vessels or lymphatics into the tissues or a cavity, such as the pleural cavity, pericardium or the peritoneum May not always contain malignant/cancer cells

question

Health record information needed to code infectious and parasitic diseases

answer

Body site with infection Severity of the disease: Acute vs. chronic Specific organism involved Etiology of infection Associated signs, symptoms, or manifestations

question

Certain Infections and Parasitic Diseases, A00-B99

answer

Chapter 1

question

Unspecified type of sepsis coded (A41.9)

answer

when a specific underlying systemic infection is not stated

question

Severe sepsis requires 2 codes

answer

code for underlying systemic infection, followed by code from category R65.2, severe sepsis

question

Septic shock requires code for underlying systemic infection

answer

followed by code R65.21, severe sepsis with septic shock. Additional codes for any other acute organ dysfunction required.

question

AIDS code B20

answer

followed by additional codes for all reported HIV-related conditions

question

Asymptomatic HIV infection

answer

status code Z21

question

Patients with inconclusive laboratory evidence of HIV

answer

code R75

question

Note for categories B95-B97

answer

that specifies that these categories are provided for use as supplementary or additional codes to identify the infectious agent(s) in diseases classified elsewhere

question

C00-C75

answer

Malignant neoplasms stated or presumed to be primary and certain specified histologies, except neuroendocrine and of lymphoid, hematopoietic, and related tissues

question

C7A

answer

Malignant neuroendocrine tumors

question

C7B

answer

Secondary neuroendocrine tumors

question

C76-C80

answer

Malignant neoplasms of ill-defined, other secondary and unspecified sites

question

C81-C96

answer

Malignant neoplasm of lymphoid, hematopoietic and related tissue

question

D00-D09

answer

In situ neoplasms

question

D10-D36

answer

Benign neoplasms except benign neuroendocrine tumors

question

D3A

answer

Benign neuroendocrine tumors

question

D37-D48

answer

Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes

question

D49:

answer

Neoplasms of unspecified behavior

question

Systemic inflammatory response syndrome (SIRS)

answer

the systemic response to infection or trauma or other insult such as cancer

question

septicemia

answer

a systemic disease associated with the presence of pathological organisms or toxins in the blood, which may include bacteria, fungi, viruses, or other organisms.

question

In situ malignancies

answer

terms also describe noninfiltrating, noninvasive, intraepithelial, or preinvasive carcinoma

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