What is the correct code to indicate an HIV positive patient has never been treated for an HIV-related condition?

June 25, 2007

Coding for HIV and AIDS
For The Record

Human immunodeficiency virus (HIV), a virus causing acquired immunodeficiency syndrome (AIDS), is transmitted through contact with bodily fluids containing infected plasma or cells. HIV may be present in any bodily fluid, such as blood, semen, vaginal secretions, breast milk, and saliva. Of the five fluids listed, transmission by saliva has not been documented. If a patient has the virus, a blood test will be positive for HIV antibodies.

Being HIV positive is not the same as having AIDS. Many patients may test positive for HIV but don’t become sick for many years. If the patient is HIV positive but is also asymptomatic—does not have an HIV-related illness—and has not been diagnosed previously with an HIV-related illness, assign ICD-9-CM code V08, Asymptomatic human immunodeficiency virus infection status. “Do not use [code V08] if the term ‘AIDS’ 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 042 in these cases” (**AHA Coding Clinic for ICD-9-CM##, 2006, fourth quarter, page 153).

Patients with inconclusive or nonspecific HIV test results should receive code 795.71, Nonspecific serologic evidence of human immunodeficiency virus.

Only confirmed cases of AIDS or HIV infection should be coded. Do not assign a code for the HIV infection if it is documented as possible, suspected, etc. This is an exception to the coding guideline that states conditions may be coded in the inpatient setting if documented as possible, probable, or suspected.

AIDS
AIDS is classified to code 042, Human immunodeficiency virus disease, which, according to ICD-9-CM guidelines, includes the following terms:

• Acquired immune deficiency syndrome;

• Acquired immunodeficiency syndrome;

• AIDS;

• AIDS-like syndrome;

• AIDS-related complex; and

• HIV infection, symptomatic.

The physician does not have to specifically document AIDS in the medical record before code 042 can be assigned. “If the physician does not diagnose AIDS, the patient may still be classified as having AIDS if he or she is infected with HIV and has the condition listed as ‘with’ or ‘due to’ HIV infection in ICD-9-CM” (**AHA Coding Clinic for ICD-9-CM##, 1992, first quarter, pages 3-4). If the patient has an HIV-related illness, code 042 should be assigned (**AHA Coding Clinic for ICD-9-CM##, 2006, fourth quarter, pages 152-154). A determination does need to be made that the condition is related to the HIV. Some conditions, known as opportunistic infections, are inherent to HIV, such as pneumocystis carinii pneumonia (136.3) and Kaposi’s sarcoma (176.x). In these cases, code 042 is assigned and sequenced as the principal diagnosis. However, other conditions may or may not be HIV-related (eg, simple pneumonia, 486). If the documentation is unclear, clarification from the physician is necessary.

The physician does not need to state that the patient has AIDS, just that the condition in question is related to HIV. If the patient has a known prior diagnosis of an HIV-related illness, assign code 042 on every subsequent admission. “Patients previously diagnosed with any HIV illness (042) should never be assigned to 795.71 or V08” (**AHA Coding Clinic for ICD-9-CM##, 2006, fourth quarter, page 153).

Sequencing of Codes
At least two codes are needed for complete coding of patients with an HIV-related illness: code 042, plus codes for the associated conditions. Ordinarily, code 042 will be sequenced as the principal diagnosis when the patient is admitted for treatment of the HIV-related illness. For example, if a patient is admitted for treatment of AIDS-related dementia, sequence code 042 as the principal diagnosis, followed by code 294.1x. A patient with an HIV infection may be admitted for treatment of an entirely unrelated condition, in which case the unrelated condition is listed as the principal diagnosis with additional codes assigned for the HIV infection (042) and the associated conditions, if any. In such cases, code 042 indicates a comorbidity rather than the reason for the hospitalization.

Most cases in the United States are due to HIV 1. However, if it is documented that the AIDS is due to HIV 2, then code 079.53 will be assigned as a secondary diagnosis after code 042.

HIV Infection in Pregnancy
If a patient is admitted during pregnancy, childbirth, or the puerperium because of an HIV-related illness, code 647.6x should be sequenced as the principal diagnosis followed by code 042 and the HIV-related illness codes. If the pregnant patient is asymptomatic, then code V08 should be assigned instead of code 042 (**AHA Coding Clinic for ICD-9-CM##, 2006, fourth quarter, page 153).

HIV Infection in Newborns
Infants from birth to the age of 18 months who test positive for HIV but do not exhibit any HIV symptoms or conditions should be assigned to code 795.71. However, if the physician documents that the patient has a diagnosis of HIV infection, then code 042 will be assigned regardless of the patient’s age.

Coding and sequencing for HIV and AIDS are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also use specific **AHA Coding Clinic for ICD-9-CM## and American Medical Association **CPT Assistant## references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

Spring has finally arrived across most of the country. The landscape is taking on the colors of blooming flowers and trees. This time of year signals new opportunities so let’s revisit one of the diagnoses that can be confusing to coders -  HIV and AIDS.  We will endeavor to better understand the disease process and requirements for documentation.  In turn, as coders, we will be better prepared to analyze record documentation, assign accurate code and identify when a query is needed.

Human Immunodeficiency Virus (HIV), is a retrovirus that destroys the immune system, disabling the body’s ability to fight infections causing some lymphomas, other malignancies, and opportunistic infections to grow.  The Official Coding Guidelines that we followed for coding HIV/ Acquired Immune Deficiency Syndrome (AIDS) in ICD-9-CM have not changed for ICD-10-CM. The only difference is that the codes have changed:

• B20 – AIDS (previously 042)
• Z21 – asymptomatic HIV status, HIV + (previously V08)

Regardless of whether a patient is newly diagnosed or has had previous admissions/encounters for HIV conditions, is irrelevant to the sequencing decisions.

• Code only confirmed cases of HIV infection/illness – Inpatient & Outpatient
• Chart documentation with qualified diagnoses such as “possible”, “probably”, “rule out”, “suspected” or “suspicion of” are never reported as AIDS (B20) – Inpatient or Outpatient

This is an exception to the rule on the Inpatient side!

• 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 HIM-related illness is sufficient.

HIV Positive:  Code Z21

Used when the patient has never been diagnosed with AIDS or an AIDS-defining condition.  Also called “asymptomatic HIV” in ICD-10-CM.

• Documentation coded as Z21 (not AIDS) – HIV positive, HIV +, HIV Infection, asymptomatic HIV, known HIV, HIV test positive. Do not use if the term “AIDS” is documented for the patient or the patient has any HIM-related illness or has a history of any HIV-related conditions.
• A diagnosis of HIV + (Z21) is not the same as a diagnosis of HIV infection, symptomatic HIV/AIDS, and AIDS (B20)

Diagnostic Criteria

For adults, adolescents, and children >18 months of age, the CDC defines AIDS as an HIV-positive patient with any one of the following:

• Current or prior diagnosis of an AIDS-defining condition

OR

• Current or prior CD4+ T-Lymphocyte count <200
• The CD4 count is a clinical indicator, however, the provider MUST document AIDS, HIV-related illness, etc., or a query is necessary.

Coding for HIV

For inpatient coding, the physician must state the diagnosis, and if not clearly documented, there is an opportunity to query for clarification.  For outpatient coding, it is often challenging for coders to determine if the patient is just HIV + (Z21) or if the patient has ever had an HIV-related illness (B20).  As of now, most outpatient coders do not have the capability to query for OP coding.  If the coder is unable to determine which the patient has based on the documentation provided, we should default to asymptomatic, rather than assigning the patient a diagnosis of AIDS.

Opportunistic Infections (OIs)

Healthy immune systems can be exposed to certain viruses, bacteria, or parasites and have no reaction to them.  However, people living with HIV/AIDS may have serious health threats from what are known as “opportunistic infections (OIs)”.  These infections attack the weakened immune system and can be life-threatening.  OIs are signs of a declining immune system.  Most life-threatening OIs occur when the CD4 count falls below 200 cells/mm3.  The CDC developed a list of more than 20 OIs that are considered AIDS-defining conditions. Patients having laboratory-confirmed HIV infections and one or more of these OIs, will be diagnosed with AIDS regardless of the CD4 count.

AIDS is the final stage of human immunodeficiency virus (HIV) infection, stage 4 by the World Health Organization (WHO) criteria (2007) and stage 3 by Centers for Disease Control and Prevention (CDC) (2008) criteria or clinical categories B or C (CDC). AIDS code (B20) applies if AIDS has ever been previously diagnosed.  B20 must always be coded on every single subsequent encounter and never again code Z21 once AIDS is assigned.

• Documentation coded as B20 –AIDS: HIC illness, HIV disease, ARC (AIDS-related complex), HIV symptomatic (any current AIDS-defining condition), HIV currently being treated for an HIV-related illness or is described as having any condition resulting from HIV + status, Acquired immune deficiency syndrome.
• Once a patient has any HIV-related illness (OI0, every subsequent encounter should be coded as AIDS (B20)
• Asymptomatic HIV (Z21) and inclusive HIV R75) are never reported once a patient has a confirmed diagnosis of AIDS.

Major AIDS-Related Conditions

Therapeutic Treatment

• Antiretroviral treatment: (HAART) combination of drugs recommended
• Pre-Exposure Prophylaxis (PrEP)
• Post-Exposure Prophylaxis treatment for occupational exposure (PEP)

-Zidovudine (Retrovir, ZDZ,AZT) and Lamivudine (Epivir, 3TC) = Combivir

-Lamivudine (Epivir, 3TC) and Stavudine (Zerit, d4T)

-Didanosine (Videx, Videx EC, ddl) and Stavudine (Zerit,d4T)

• Fulyzag for treatment of antiretroviral treatment-induced diarrhea

A lot of information is included that I trust will clarify the assignment of HIV and AIDS as well as opportunities for the query. Take time to enjoy the Spring!

REFERENCES

1. Reference: Optum: Guide to Clinical Validation, Documentation and Coding (2014) p.34
2. References: 2016 CDI Pocket Guide by R. D. Pinson, MD, FACP, CCS & C. L. Tang, RHIA, CCS. p.87, 88.
3. Reference: Optum: Guide to Clinical Validation, Documentation and Coding (2014) p.30.
4. Reference: U.S. Department of Health and Human Services. Potential Health Related Problems: Opportunistic Infections. www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids  (2016).
5. References: ICD-10-CM Official Guidelines and Reporting 2017 1.a.1.2

About the Author

Marie Thomas holds a Masters in Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please comment below.