Coding for ICD-10 coding for HIV and AIDS
Question: Patient is diagnosed with symptomatic HIV. What ICD-10-CM code is reported?
B20, Human immunodeficiency virus [HIV] disease
Locate and Verify
In the ICD-10-CM Alphabetic Index, see HIV, B20. You can also look under Human immunodeficiency virus (HIV) disease, (infection), B20. In the Tabular, B20 can be verified as Human immunodeficiency virus [HIV] disease. This code includes:
- acquired immune deficiency syndrome [AIDS]
- AIDS-related complex [ARC]
- HIV infection, symptomatic
Be sure to read all the notes at B20 under “Code first,” “Use additional code(s)…,” and “Excludes” notes:
- Code First: Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth, and the puerperium, if applicable (O98.7-)
- Use additional code(s) to identify all manifestations of HIV infection
- Excludes1: Asymptomatic human immunodeficiency virus [HIV]; infection status (Z21); exposure to HIV virus (Z20.6); inconclusive serologic evidence of HIV (R75)
More Instructional Notes
At the beginning of Chapter 1, there are instructional notes that apply to A00-B99 as follows:
- Includes: diseases generally recognized as communicable or transmissible
- Use additional code to identify resistance to antimicrobial drugs (Z16.-)
- Excludes1: certain localized infections – see body system-related chapters
- Excludes2: carrier or suspected carrier of infectious disease (Z22.-); infectious and parasitic diseases complicating pregnancy, childbirth and the puerperium (O98.-); infectious and parasitic diseases specific to the perinatal period (P35-P39); influenza and other acute respiratory infections (J00-J22)
According to the ICD-10-CM Official Guidelines for Coding and Reporting:
- A diagnosis of HIV must be confirmed in order to code for it. This is an exception to the hospital inpatient guideline in Section II, H. In this context, “confirmation” does not require documentation of positive serology or culture for HIV; the provider’s diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient.
- If a patient is admitted for an HIV-related condition, B20 should be assigned as the principal diagnosis followed by additional codes for all reported HIV-related conditions.
- If a patient has HIV and is admitted for a condition unrelated to HIV, the unrelated condition should be assigned as the principal diagnosis followed by B20 for HIV.
- Whether the patient is newly diagnosed or has had previous encounters or admissions for HIV conditions has no bearing on the code sequencing.
- If the documentation indicates the patient has no symptoms of HIV but is listed as “HIV positive,” “known HIV,” “HIV test positive,” or similar terminology, Z21, Asymptomatic human immunodeficiency virus infection status, should be assigned.
- If a patient has inconclusive HIV serology but no definitive diagnosis or manifestations of the illness, R75, Inconclusive laboratory evidence of human immunodeficiency virus [HIV], should be assigned.
- Once a patient has been diagnosed with an HIV-related illness, B20 should be assigned on every subsequent admission or encounter, whether the patient is currently exhibiting symptoms or not. A patient with a previous diagnosis of any HIV illness (B20) should never be assigned to R75 or Z21.
- During pregnancy, childbirth, or the puerperium, a patient who is admitted or presents for an encounter due to an HIV-related illness should be assigned a principal diagnosis of O98.7-, Human immunodeficiency [HIV] disease complicating pregnancy, childbirth, and the puerperium. This should be followed by B20 and the codes for the HIV-related illnesses. Codes from Chapter 15 always take sequencing priority.
- A patient with asymptomatic HIV infection status who is admitted or presents for an encounter during pregnancy, childbirth, or the puerperium should receive codes O98.7- and Z21.
- A patient being seen to determine his/her HIV status should be assigned Z11.4, Encounter for screening for human immunodeficiency virus [HIV]. Additional codes should be used for any associated high-risk behavior.
- If the patient is being seen for HIV testing and has signs or symptoms, the signs and symptoms should be coded. An additional counseling code Z71.7, Human immunodeficiency virus [HIV] counseling, may be assigned if counseling is provided during the encounter for the test.
- When a patient returns for results of his/her HIV status and the results are negative, Z71.7, Human immunodeficiency virus [HIV] counseling, should be assigned. If the results are positive, refer to previous guidelines and assign codes as appropriate.
What is HIV?
HIV (human immunodeficiency virus) is a virus that attacks cells that help the body fight infection, according to HIV.gov. This causes a person to be more susceptible to other infections and diseases.
HIV can be spread through certain bodily fluids when a person has contact with another person with HIV. It is most often spread through unprotected sex or through drug use, but it may also be passed on to a newborn by an infected mother. HIV that goes untreated can result in AIDS (acquired immunodeficiency syndrome).
There is no cure for HIV, so once you have it, you always have it. Symptoms usually begin with a flu-like illness that can last a few days to several weeks. Then it goes into latency where there may be no symptoms and may last 10 to 15 years. The late stage of HIV infection is AIDS and may occur without HIV treatment. Symptoms of AIDS may include, among others, rapid weight loss, pneumonia, and neurologic disorders.
This post has been updated to reflect FY 2021 ICD-10-CM coding guidelines.
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