Review HIV, ARC, and AIDS-related Encounters

Review HIV, ARC, and AIDS-related Encounters

Look beyond coding guidelines for complete and accurate reporting.


In 2011, more than 1.2 million people in the United Sates were living with the human immunodeficiency virus (HIV), and only four in 10 of those individuals were in HIV medical care. Couple those numbers with the nearly $23 billion in federal funding the United States budgeted for HIV and acquired immunodeficiency syndrome (AIDS)-related medical services in 2014, and you begin to understand why proper reporting of these services is paramount.

Source: Centers for Disease Control and Prevention (CDC) Vital Signs Fact Sheet, November 2014

The differences between HIV, AIDS, and AIDS-related complex (ARC), from clinical and coding perspectives, can be perplexing. To ensure proper reporting, it’s essential that you understand not only coding guidelines, carrier instructions, and contract requirements, but also provider terminology, patient physiological responses related to the illness, and clinically significant illness-related diagnostic criteria.

Diagnostic Spectrum of HIV

HIV, ARC, and AIDS each represent a different step in the evolution of HIV disease in a patient. Even if a patient’s condition improves, he or she cannot move backwards on the diagnostic spectrum. Once a patient falls into the symptomatic HIV category (B20 Human immunodeficiency virus [HIV] disease), his or her HIV care is reported with B20 from that point forward, even if the patient’s condition improves to the point where he or she appears asymptomatic.

HIV is an infective agent affecting the body’s immune system and its ability to fight infection. When a patient is first infected, typically he or she does not display any symptoms of illness. It may take three to six months after infection before HIV antibodies are detected in typical laboratory tests. As the disease evolves (which may take ears), symptoms may arise that signal a transition symptomatic HIV infection (which is not synonymous with AIDS). The symptoms signaling transition are considered to be ARC. At some point, those symptoms progress to the extent that either the patient’s immune system becomes severely compromised (based on the patient’s CD4 cell count), or the patient develops an opportunistic infection (see Opportunistic Infections list). When either of these two things occurs, a patient is considered to have AIDS (aka Stage 3 HIV).

With a preliminary understanding of the terminology, physiology, and diagnostics, you can look at the coding guidelines related to the HIV disease process. There are seven codes directly related to HIV-related care:

Z11.4 Encounter for screening for human immunodeficiency virus (HIV)

Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus (HIV)

Z71.7 Human immunodeficiency virus (HIV) counseling

R75 Inconclusive laboratory evidence of human immunodeficiency virus (HIV)

Z21 Asymptomatic human immunodeficiency virus (HIV) infection status

B20 Human immunodeficiency virus [HIV] disease

O98.7- Human immunodeficiency (HIV) disease complicating pregnancy, childbirth and the puerperium

There are specific circumstances for which each of these codes is reported. The reasons why patients seek HIV-related care can be divided into three main categories: testing, results of testing, and HIV-positive patients needing care.

Testing to Determine HIV Status

There are three reasons a patient may present for HIV testing:

  1. Screening: A patient seeking HIV screening, who does not have any signs or symptoms of HIV disease and who has not been exposed to the HIV virus.

Common examples: Individuals planning to become sexually active with a new partner and wanting to prove they are not infected with a sexually transmitted disease (STD); individuals applying to adopt a child; individuals applying for life insurance.

Coding for HIV screening:

  • Z11.4 for HIV screening

If applicable:

  • Associated high-risk behaviors
  • Z71.7 for HIV counseling provided during the encounter
  1. Exposure: A patient seeking HIV testing due to exposure, who does not have any signs or symptoms of HIV disease.

Common examples: Individuals suffering from a needlestick injury used on a patient known to have HIV; individuals who had unprotected sex with a partner who has HIV.

Coding for HIV exposure:

  • Z20.6 for contact and suspected exposure

If applicable:

  • Associated high-risk behaviors
  • Z71.7 for HIV counseling provided during the encounter
  1. Signs/Symptoms: A patient seeking HIV testing due to signs and symptoms, regardless of whether he or she knowingly has been exposed to the virus. By the time a patient experiences signs and symptoms, he or she likely has had the disease for years.

Common examples: Individuals suffering from rapid weight loss, recurring fevers and night sweats, extreme and unexplained fatigue, prolonged swelling of lymph glands, diarrhea lasting more than a week, etc.

Coding for HIV signs/symptoms:

  • Specific signs/symptoms

If applicable:

  • Associated high-risk behaviors
  • Z71.7 for HIV counseling provided during the encounter

Results of HIV Testing

There are four potential outcomes for HIV testing:

  1. Negative: A patient presents for HIV testing results, which are negative (there is no presence of the disease). During this encounter, the provider discusses with the patient why he or she felt the need to be tested, ways to prevent exposure in the future (e.g., safe sex practices), etc. The topics discussed during these encounters support the guidelines directing you to use the HIV counseling code. It’s important to remember that a patient does not have to be HIV positive to report the HIV counseling code for services rendered during an encounter.

Coding for HIV results – negative:

  • Z71.7 for HIV counseling
  1. Inconclusive: A patient presents for HIV testing results, which are inconclusive (test results do not clearly show whether the patient has HIV). The patient does not have any signs, symptoms, or manifestations of the disease. This primarily occurs when the test is conducted before the HIV antibodies have developed. An example is children born to HIV-positive mothers. For approximately the first 18 months of life, a child has the mother’s antibodies; therefore, the test must be conducted after 18 months of age (when the child has his or her own antibodies) to ensure test results are accurate.

Coding for HIV results – inconclusive:

  • R75 for inconclusive laboratory evidence of HIV
  1. Positive without symptoms: A patient presents for HIV testing results, which are positive (patient has the disease). The patient has no signs or symptoms of the disease outside of the positive laboratory test.

Coding for HIV results – positive without symptoms:

  • Z21 for the asymptomatic HIV infection status
  1. Positive with symptoms: A patient presents for HIV testing results, which are positive (patient has the disease). The patient has signs or symptoms of the disease.

Coding for HIV results – positive without symptoms:

  • B20 for HIV disease

Important: Only confirmed cases of HIV infection/illness may be coded. However, confirmation does not require documentation of positive serology or culture for HIV. The provider’s diagnostic statement alone is sufficient.

HIV Positive Patients Needing Care

There are three situations in which an HIV-positive patient will seek care:

1. HIV-related illness: A patient being seen for an HIV-related illness is seeking care for an infection or manifestation related to, or brought on by, HIV disease.

Common examples: HIV-positive individuals being treated for thrush, shingles, pneumonia, etc. (See Opportunistic Infections on page 13 for more related conditions.)

Coding for HIV-related illnesses:

  • B20 for HIV disease
  • All documented HIV-related conditions

Illness unrelated to HIV: A patient being seen for conditions unrelated to his or her HIV disease.

Common examples:

  • Individuals suffering from traumatic injuries (e.g., fracture, burn)

Coding for care unrelated to HIV disease:

  • Unrelated condition
  • B20 for HIV disease
  • All documented HIV-related conditions

Pregnancy: An HIV-positive woman receiving care during her pregnancy. Code order for care during pregnancy does not depend on whether the condition being addressed is HIV-related. All conditions occurring during pregnancy are considered to affect the pregnancy, including HIV.

Coding for pregnancy care for an HIV-positive patient:

  • O98.7- for HIV disease complicating pregnancy, childbirth, and the puerperium
  • Appropriate HIV code – Either: Z21 for asymptomatic HIV infection status or B20 for HIV disease
  • Z3A.- Weeks of gestation

Hone in on Proper Dx Coding with Case Examples

We’ve covered the basic terminology, physiology, and coding for HIV, ARC, and AIDS related care. Now, let’s review some specific examples.

Example 1: Jane presents for HIV testing. She acknowledges she is sexually promiscuous and recently received a call from one of her partners, informing her that he tested positive for HIV. Jane states she doesn’t always practice safe sex. The doctor discusses with Jane the importance of safe sex practices, the possible need for additional testing if results are indeterminate, and the next steps if her test results are positive.

ICD-10-CM coding: Z20.6, Z72.51 High risk heterosexual behavior, Z71.7

Example 2: Jane returns to the office to receive her HIV test results. The results are positive; however, she is not yet experiencing any symptoms of the disease. The doctor discusses with Jane options for treatment, importance of medication compliance, and the need to contact former sexual partners to disclose her HIV-positive status.

ICD-10-CM coding: Z21, Z71.7

Example 3: Jane presents for routine pregnancy care and is 17 weeks into her pregnancy. She was previously diagnosed with HIV, but has not experienced any symptoms. The doctor discusses with Jane recent lab results, which reveal she is anemic.

Note: Anemia during pregnancy is more common in HIV positive women. Knowing this, best practice is to review the documentation further and query the provider if needed to determine if the anemia is HIV-related and should be coded as such. For this scenario, there is no documentation to indicate the anemia is HIV-related.

ICD-10-CM coding: O98.712 Human immunodeficiency virus [HIV] disease complicating pregnancy, second trimester, Z21, O99.012 Anemia complicating pregnancy, second trimester, Z3A.17 17 weeks gestation of pregnancy

Reporting HIV/ARC/AIDS is serious business. Because there is so much at stake, coders/billers/auditors must thoroughly understand this complicated disease and all of its coding and reporting nuances.

Anesthesia and Pain Management CANPC


Chandra Stephenson, CPC, COC, CPB, CPCO, CPMA, CPC-I, CIC, CCS, CANPC, CEMC, CFPC, CGSC, CIMC, COSC, is a consultant who started out in healthcare 10 years ago. She has worked in a centralized billing office, a family practice office, a cardiology office, as a billing and coding instructor at a local technical college, and as a coding and compliance auditor. She enjoys conducting audits, researching coding and compliance issues, developing coding tools, and providing practitioner education. She is a member of the AAPC National Advisory Board and the Indianapolis local chapter.

One Response to “Review HIV, ARC, and AIDS-related Encounters”


    Educative article and also great to know four potential outcomes for HIV testing.

Leave a Reply

Your email address will not be published. Required fields are marked *