Coding for HIV

Overview

We’re going to go over the guidelines and sequencing required to accurately code for HIV (Human Immunodeficiency Virus).

Goals

1. Know when to assign B20 (HIV) as the first-listed diagnosis

2. Visits for HIV screening

3. HIV infection in pregnancy

4. Asymptomatic human immunodeficiency virus

5. Visits with patients with HIV for unrelated reasons
   

First-listed HIV (B20)

You should only be coding for confirmed cases, and if a patient is being seen for an HIV-related reason, then B20 must be sequenced first, following the other related diagnosis codes.

Encounters For Testing

If a patient is being seen to determine if they have contracted HIV, use code Z11.4, Encounter, for screening for human immunodeficiency virus (HIV). If there are any High-risk signs or symptoms, you must code those until HIV has been confirmed.

Example:

A patient presents for HIV screening; the patient is asymptomatic.

Code: Z11.4, Encounter for screening for HIV

Even though it says the patient is asymptomatic, the reason for the visit is to screen for HIV. We still don’t know if the patient is actually asymptomatic yet.

HIV In Pregnancy

If a pregnant patient is admitted for an HIV-related illness code from Chapter 15, O98.7, HIV disease complicating pregnancy, followed by B20 (HIV), then any HIV-related diagnosis codes.

Asymptomatic HIV

If a patient has tested positive for HIV and shows no sign or symptoms of having the disease, it would be appropriate to assign a status code, Z21, asymptomatic HIV. Do not use this status code when the illness is described to be AIDS or HIV-related in nature. In those situations, you want to either code for AIDS or HIV (B20).

Visits With HIV Patients For Unrelated Reasonsn

If a patient who is HIV positive is seen for an unrelated illness (injury, etc.), then that unrelated illness should be sequenced first, followed by B20 (HIV) and any other relevant diagnoses.