Internal Medicine Coding Alert

Compare yours to those of our experts.

Answer 1:The answer to this question depends on the stage of the infection the patient is in.

After being tested for HIV, a patient could be given a diagnosis of Z21 (Asymptomatic human immunodeficiency virus [HIV] infection status). Coding Z21 means that the patient is HIV positive but has yet to show any of the HIV-related conditions or opportunistic infections that are associated with the disease.

"Using Z21 when the patient is asymptomatic is ideal," agrees Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. "If a patient presents with an illness such as a cough or a cold, listing this as a secondary diagnosis is a good option to demonstrate the patient has a chronic condition that could contribute to the complexity of the primary diagnosis."

One code that Holle suggests you should not use is R75 (Inconclusive laboratory evidence of human immunodeficiency virus [HIV]). "If HIV is suspected," Holle explains, "and the physician ordered lab work, some offices are tempted to use the R75 code for inconclusive laboratory evidence of HIV if there is not a diagnosis of HIV made yet." However, Holle recommends you use signs and symptoms, and not R75, until the provider makes a definitive diagnosis.

This can only happen when the patient has moved to the third stage of HIV, where it is now possible for that patient to develop one of a number of opportunistic infections associated with the disease. At this point, you can use the definitive code B20 (Human immunodeficiency virus [HIV] disease), as the patient can be said to have symptomatic HIV, or acquired immunodeficiency syndrome (AIDS).

But, as Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, cautions, "Be careful to label a patient as HIV positive only if the medical record definitively supports that diagnosis." "For instance," Moore advises, "some patients may be exposed to HIV without actually being infected." In which case, you might code Z20.6 (Contact with and (suspected) exposure to human immunodeficiency virus [HIV]).

Answer 2:The answer to this question depends on the reason for the patient encounter. If the primary reason for the office visit is for a condition that has manifested due to AIDS, then you would code B20 first in the sequence.

For example, you would code a patient reporting with Kaposi's sarcoma - an opportunistic cancer common to those affected by HIV that affects the skin, the mucous membranes that line the nose, throat, and mouth, and sometimes even the lymph nodes and internal organs - this way:

• B20 - Human immunodeficiency virus [HIV] disease)
• C46.- - Kaposi's sarcoma.

"The key," according to Moore, "is to identify the codes for the conditions you intend to report and follow the guidance ICD-10 provides in each case." In this case, there is a note accompanying C46- that says, "Code firstany human immunodeficiency virus [HIV] disease" and a corresponding note following B20 that says, "Use additional code(s) to identify all manifestations of HIV infection."

And, Moore continues, "If ICD-10-CM does not specify a sequence among the codes in question, then align the diagnosis codes with the reasons for the visit." So, the correct code sequence for a patient that comes in with an unrelated condition, such as dislocated right thumb, would be

• S63.1- - Subluxation and dislocation of thumb
• B20 - Human immunodeficiency virus [HIV] disease).

Answer 3:Even though there is a completely separate code for this diagnosis - O98.7- (Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium) - you would add Z21 if the patient was asymptomatic, or B20 if she was symptomatic. Either code would be sequenced second as, according to ICD-10-CM guideline 15. a. 1., "Chapter 15 codes have sequencing priority over codes from other chapters." Also, a note under O98.7- directs you to "Use additional code to identify the type of HIV disease," which would be either Z21 or B20.

You would also add the appropriate fifth and sixth digits to O98.7- to specify the trimester or whether the encounter was before or after the patient gave birth. And if the encounter occurred during the pregnancy, you would add another code from Z3A.- (Weeks of gestation) to indicate how many weeks the patient was into the pregnancy.

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