Table of Contents

Coding guidelines for HIV

B20 reports human immunodeficiency virus diseases and includes AIDS (acquired immune deficiency syndrome), which is caused by HIV (human immunodeficiency virus). HIV affects certain white blood cells (T-4 lymphocytes) and destroys the ability of the cells to fight infections, making patients susceptible to a host of infectious diseases (e.g., Pneumocystis carinii pneumonia [PCP], Kaposi’s sarcoma, and lymphoma). AIDS-related complex (ARC) is an outdated term for lesser infections associated with HIV. Additional code(s) are reported to identify all the manifestations of AIDS.

It is extremely important that only confirmed HIV cases are reported. The assignment of the AIDS code prior to confirmation may cause the patient many unwarranted problems if the patient does not have AIDS. Confirmation does not mean that a serology or culture for HIV is positive, but rather that the physician has documented that the patient is HIV positive or has HIV-related illnesses. If the encounter is for an HIV-related condition, the first-listed diagnosis is B20 with additional codes to report the HIV-related condition(s). If the encounter is for an HIV-disease patient for other than the HIV or an HIV-related condition, the reason for the encounter is the first-listed diagnosis followed by B20.

There are times when a patient is documented to be HIV-positive based on serology or culture but has no symptoms. Report this asymptomatic HIV status with Z21, Asymptomatic HIV status. However, once a patient has AIDS, report B20; never report R75 (inconclusive) or Z21 (asymptomatic). If the patient is known to have been exposed to HIV but has not tested positive for HIV and has no HIV symptoms, report Z20.6. If the serology for HIV is inconclusive, report R75

If an HIV-positive patient is pregnant and the encounter is for an HIV-related illness, the first-listed diagnosis is O98.7, HIV disease complicating pregnancy, childbirth, and the puerperium, followed by B20 and codes for the HIV-related illness. If the patient’s status is asymptomatic HIV, report O98.7 and Z21 (asymptomatic HIV).
If the patient presents for HIV testing, report Z11.4, Encounter for screening for HIV. Additional codes may be assigned for any known high-risk behavior, such as:
Z72.51 High risk heterosexual behavior
Z72.52 High risk homosexual behavior
Z72.53 High risk bisexual behavior

If the patient has signs or symptoms when presenting for HIV screening, report the signs and symptoms and if counseling is provided during the encounter, report Z71.7, HIV counseling. When the patient returns for the results of the HIV screening and the results are negative, report Z71.7.

We have separate coding guidelines for coding HIV in ICD 10. There can be the lot of confusion of coding HIV, AIDS and HIV related diseases, hence we should always follow the ICD 10 coding guidelines. There are few specific points one should remember while coding HIV related diagnosis. Below are the ICD coding guidelines with the ICD 10 codes which should be reported in the respective scenarios.

When the patient is treated for an illness that’s related to HIV, as per coding guidelines we have to report B20 (Human immunodeficiency virus [HIV] disease) first, then the code for the illness being treated. However, if the problem being treated is unrelated to the patient’s HIV, report B20 as the secondary diagnosis and code primary for the condition being treated.

If the HIV-positive patient is pregnant or immediately post-partum and presents because of an HIV-related illness, as per ICD-10 guidelines you have to first sequence O98.7 (HIV disease complicating pregnancy, childbirth and the puerperium), followed by B20 and the code for the HIV-related illness.

When the patient’s HIV status is not established, we have to report the inconclusive lab evidence of HIV, R75 ICD 10 code. In ICD 9 we use to report 795.71.