Find information on Exposure to Bodily Fluids, including Needlestick Injury and Contact with Hazardous Fluids. Learn about bloodborne pathogen exposure, clinical documentation requirements, and medical coding for E codes related to Exposure to Bodily Fluids. This resource provides guidance for healthcare professionals on managing and documenting these exposures in accordance with best practices.
Also known as
Contact with and suspected exposure to
Covers contact with and suspected exposure to venomous animals and plants, biological and chemical substances.
Place of occurrence of external cause
Specifies the location where the event occurred that caused the injury.
Other and unspecified effects of external causes
Includes effects like exposure to radiation, and other not elsewhere classified external cause effects.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the exposure occupational?
Yes
Source known?
No
Source known?
When to use each related code
| Description |
|---|
| Exposure to blood or other bodily fluids. |
| Accidental puncture wound by a sharp object. |
| Infection acquired from exposure to blood. |
Lack of specific fluid documentation (blood, saliva, etc.) can lead to coding errors and rejected claims. CDI can query for clarity.
Missing details about the exposure source (e.g., accidental needlestick, splash) impacts accurate coding and risk assessment for compliance.
Lack of documentation on post-exposure prophylaxis or follow-up creates audit risks and hinders proper healthcare management.
Q: What is the recommended post-exposure prophylaxis (PEP) for occupational exposure to HIV after a needlestick injury involving a source with unknown HIV status?
A: The recommended post-exposure prophylaxis (PEP) for occupational HIV exposure following a needlestick injury from a source with unknown HIV status depends on the risk assessment. Factors to consider include the type of exposure (e.g., depth of injury, device visibility in the source), the fluid involved (e.g., blood, visibly bloody fluid, other potentially infectious material), and the prevalence of HIV in the source population. According to guidelines from the Centers for Disease Control and Prevention (CDC), if the risk is determined to be substantial, a 4-week regimen of a combination antiretroviral regimen should be initiated as soon as possible, ideally within 2 hours of exposure. If the source is later determined to be HIV-negative, PEP can be discontinued. For lower-risk exposures, no PEP may be warranted. Consider implementing a standardized risk assessment protocol in your facility to guide decision-making in occupational exposures. Explore how S10.AI can help you manage occupational exposures and automate documentation.
Q: How do I perform a risk assessment for bloodborne pathogen exposure involving a splash to the mucous membrane (eye, nose, mouth)?
A: A risk assessment for bloodborne pathogen exposure following a splash to a mucous membrane (eye, nose, or mouth) must evaluate the type of fluid, the amount of fluid involved, and the source's infectious status. Consider whether the fluid contained visible blood, was a concentrated source of pathogens, or involved a large volume. The source's hepatitis B, hepatitis C, and HIV status are critical in determining the necessary follow-up. If the source has a known bloodborne infection, appropriate testing and prophylaxis should be initiated according to CDC guidelines. Even if the exposure source is unknown, baseline testing of the exposed healthcare worker is recommended. Learn more about evidence-based practices for managing occupational exposures to optimize patient and clinician safety. Explore how S10.AI can facilitate accurate documentation and reporting of occupational exposures.
Patient presented following occupational exposure to bodily fluids. The incident involved a needlestick injury during venipuncture procedure. The patient reported immediate localized pain at the site of the puncture wound. Assessment revealed a small puncture wound on the left dorsal hand with minimal bleeding. The source patient's bloodborne pathogen status is currently unknown and testing is underway. The incident was immediately reported according to established protocols. Post-exposure prophylaxis options were discussed, including HIV PEP and HBV vaccination status was reviewed. Patient education provided regarding signs and symptoms of bloodborne infections, including HIV, Hepatitis B, and Hepatitis C. Follow-up appointments scheduled for baseline and subsequent bloodborne pathogen testing. Incident documentation completed and filed with occupational health. Counseling provided regarding emotional distress related to potential exposure. ICD-10 code Z20.822, Contact with and suspected exposure to bloodborne pathogens, is documented. The medical necessity for post-exposure prophylaxis and follow-up testing has been established.