Wiki HIV infection

kumeena

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patient came to ED for fracture and HIV infection was documented in past history. Because of the term "infection" is it 042 ?

Even though the doctor did not write anything should we code for that?

Thanks for your help
 
It is very important to review the guidelines in the ICD-9 book in regards to HIV/ AIDS coding.

You would code the condition as V08. This code is used for asymptomatic HIV infection.

ICD-9 Code 042 is used for AIDS. If the physician documented the patient has AIDS or in the history it is mentioned the patient had an AIDS defining illness (Kaposi Sarcoma), then you would code the condition to 042.

I attached an example from AHA Coding on how to deal with the diagnosis coding for asymptomatic HIV.


Year: 1994

Issue: Fourth

Title: HIV infection, asymptomatic

Body: 10.6 Asymptomatic HIV Infection

V08 Asymptomatic human immunodeficiency virus [HIV] infection,is applied when a 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 code 042 in these cases.

Example:

A patient is admitted for treatment of rheumatic heart disease. He is found to have mild tricuspid insufficiency. Five months ago, the patient tested positive for HIV, but has not yet shown any symptoms of HIV disease.

Principal diagnosis:

397.0 Diseases of the tricuspid valve

Other diagnosis:

V08 Asymptomatic HIV infection
 
HIV disease is what happens before AIDS. In order to get HIV, you have to be infected. See the information posted below from the CDC website (See Below).

The key to diagnosis coding for HIV and AIDS was the AHA Coding Clinic I posted above:

V08 Asymptomatic human immunodeficiency virus [HIV] infection,is applied when a 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 code 042 in these cases





http://www.cdc.gov/hiv/resources/brochures/livingwithhiv.htm#q2


What is the difference between HIV and AIDS?
HIV is the virus that causes the disease AIDS. Although HIV causes AIDS, a person can be infected with HIV for many years before AIDS develops.

When HIV enters your body, it infects specific cells in your immune system. These cells are called CD4 cells or helper T cells. They are important parts of your immune system and help your body fight infection and disease. When your CD4 cells are not working well, you are more likely to get sick.

Usually, CD4 cell counts in someone with a healthy immune system range from 500 to 1,800 per cubic millimeter of blood. AIDS is diagnosed when your CD4 cell count goes below 200. Even if your CD4 cell count is over 200, AIDS can be diagnosed if you have HIV and certain diseases such as tuberculosis or Pneumocystis carinii [NEW-mo-SIS-tis CA-RIN-nee-eye] pneumonia (PCP).

There are general stages of HIV infection that you may go through before AIDS develops.

Infection. The earliest stage is right after you are infected. HIV can infect cells and copy itself before your immune system has started to respond. You may have felt flu-like symptoms during this time.

Response. The next stage is when your body responds to the virus. Even if you don’t feel any different, your body is trying to fight the virus by making antibodies against it. This is called seroconversion, when you go from being HIV negative to HIV positive.

No symptoms. You may enter a stage in which you have no symptoms. This is called asymptomatic infection. You still have HIV and it may be causing damage that you can’t feel.

Symptoms. Symptomatic HIV infection is when you develop symptoms, such as certain infections, including PCP.

AIDS. AIDS is diagnosed when you have a variety of symptoms, infections, and specific test results. There is no single test to diagnose AIDS.
 
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