Internal Medicine Coding Alert

Reader Question:

HIV Patient Visit

Published on Fri Nov 01, 2002

Question: If a patient is HIV-positive, should a physician code this as part of the patients diagnosis, even if the physician is not treating the HIV at a particular visit?

Pennsylvania Subscriber

Answer: Physician coding guidelines state that you should code only diagnoses that are addressed at that particular encounter. If the HIV is a contributing factor to the patients condition (for example, the patient has an acute upper respiratory infection and the HIV plays a significant role in treatment), you can code it as a secondary diagnosis. But if the patient comes in for a complaint when the HIV is not a factor (for example, a twisted ankle), you should not list the HIV diagnosis with that visit.

Keep in mind that most if not all states have laws or regulations relating to what we think of as "super confidential" information, and this usually includes a patients HIV status. In these cases, the patient or the patients legal representative must sign a form specifically allowing the release of HIV-related information, including disclosure of an HIV diagnosis. Release of any "super confidential" information (HIV- or AIDS-related information, substance or alcohol abuse treatment, or psychological records) without a signed form can leave your physician open to charges that he or she violated patient confidentiality and privacy laws.

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