ICD-10 Coding for HIV and AIDS

ICD-10 coding for HIV and AIDS begins with knowing what to look for in the documentation and the coding guidelines and sequencing rules. Try your skill on this Name That Code! practice exercise and then compare your answer to the one provided.  

Name That Code!

Question: Patient is diagnosed with symptomatic HIV. What ICD-10-CM code is reported?

Answer:

B20, Human immunodeficiency virus [HIV] disease

Locate and Verify

In the ICD-10-CM Alphabetic Index, look up HIV, B20. You can also look under Human immunodeficiency virus (HIV) disease, (infection), B20.

We can verify our correct code in the Tabular as:

B20, 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)

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How Well Do You Know Your ICD-10-CM Coding Guidelines on HIV and AIDS? Go here to take the quiz to find out. Then come back and try your skill on this Name That Code! coding exercise again.

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Coding Guidelines

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. Documentation such as “possible”, “probable,” or “suspected” HIV is not a confirmed diagnosis and cannot be reported as such. So, it doesn’t matter if we are coding for an inpatient encounter or an outpatient encounter; a diagnosis of HIV must be confirmed to code for it. In this coding scenario, it is confirmed.

• 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 [HIV]) infection status, should be assigned. Do not use this code if the term “AIDS” or “HIV disease” 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 B20 in these cases.

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 2022 ICD-10-CM coding guidelines.  

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