Wiki HIV screening or exposure to HIV

[BHolly]

How would you code this question from one of the ICD-10 studyguides?
A very worried patient consulted her primary care physician after finding out her boyfriend tested positive for HIV. Today she underwent testing and counseling and will be contacted when results come back.

I coded it as HIV exposure Z20.6 and HIV counseling Z71.7.
The answer in book was screening for HIV Z11.4 and counseling Z71.7

Why would it be screening if we know the patient was exposed? Please explain.

 

[mitchellde]

It would be exposure if the documentation included that she has engaged on unprotected sex with this person

 

[AlaskanCoder]

My first inclination would be to answer it as you did. However, after having completed the AHIMA Train the Trainer program and a few other courses that provide rationale for their answers, I realize that the thinking of the exam writers is that there is no documentation of exposure. We are making an assumption that the patient has a sexual relationship with her boyfriend, because it is not mentioned in this statement.
The chapter 1 specific guidelines for ICD-10 say "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." So, this is why you should not code exposure for the screening.

Karen Hill, CPC, CPB, CPMA
AHIMA Approved ICD-10-CM Trainer