ICD-10-CM Sneak Peak: HIV

By Rhonda Buckholtz, CPC, CPC-I, CGSC, CPEDC, COBGC, CENTC

Let’s take a first look at how to code for HIV in ICD-10-CM. With a little help from the guidelines we will be well on our way. Familiarity with guidelines prior to code selection will help us along the way to proper code selection. Below is an excerpt from the Draft ICD-10-CM Guidelines regarding HIV coding.

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)

Human Immunodeficiency Virus (HIV) Infections

1) Code only confirmed cases

Code only confirmed cases of HIV infection/illness.

This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of positive serology or culture for HIV; the provider’s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient.

2) Selection and sequencing of HIV codes

Patient admitted for HIV-related condition: 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.

Patient with HIV disease admitted for unrelated condition: If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the principal diagnosis. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions.

Whether the patient is newly diagnosed: Whether the patient is newly diagnosed or has had previous admissions/encounters for HIV conditions is irrelevant to the sequencing decision.

Asymptomatic human immunodeficiency virus: Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” or similar terminology. Do not use this code if the term “AIDS” is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases.

Patients with inconclusive HIV serology: Patients with inconclusive HIV serology but no definitive diagnosis or manifestations of the illness, may be assigned code R75, Inconclusive laboratory evidence of human immunodeficiency virus [HIV].

Previously diagnosed HIV-related illness: Patients with any known prior diagnosis of an HIV-related illness should be coded to B20. Once a patient has developed an HIV-related illness, the patient should always be assigned code B20 on every subsequent admission/encounter. Patients previously diagnosed with any HIV illness (B20) should never be assigned to R75 or Z21, Asymptomatic human immunodeficiency virus [HIV] infection status.

HIV Infection in Pregnancy, Childbirth and the Puerperium: During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of an HIV-related illness should receive a principal diagnosis code of O98.7-, Human immunodeficiency [HIV] disease complicating pregnancy, childbirth and the puerperium, followed by B20 and the code(s) for the HIV-related illness(es). Codes from Chapter 15 always take sequencing priority.

Patients with asymptomatic HIV infection status admitted (or presenting for a health care encounter) during pregnancy, childbirth, or the puerperium should receive codes of O98.7- and Z21.

Encounters for testing for HIV: If a patient is being seen to determine his/her HIV status, use code Z11.4, Encounter for screening for human immunodeficiency virus [HIV]. Use additional codes for any associated high risk behavior. If a patient with signs or symptoms is being seen for HIV testing, code the signs and symptoms. An additional counseling code Z71.7, Human innunodeficiency virus [HIV] counseling, may be used if counseling is provided during the encounter for the test.

When a patient returns to be informed of his/her HIV test results and the test result is negative, use code Z71.7, Human immunodeficiency virus [HIV] counseling. If the results are positive, see previous guidelines and assign codes as appropriate.

Take a look at the following coding example:

A patient with AIDS is seen by her physician for severe dehydration. The final diagnosis by the physician is Samonella with dehydration.

In this example the code for HIV would be sequenced last as it was not the reason for the encounter. The scenario would be coded A02.9 (for the salmonella), E86.0 (dehydration), B20 (HIV).

As in ICD-9-CM, careful attention to coding guidelines is imperative to proper coding selections and successful ICD-10-CM coding.