MDS Alert

Hint: Defining illnesses may be key.

If you are caring for a resident with HIV/AIDS and wondering how to document the presence of either disease in Section I (Active Diagnoses) of the MDS, it’s crucial that you understand the difference in ICD-10 coding for each condition.

“Oftentimes there is a need for additional supportive documentation in determining the appropriate ICD-10 for HIV,” says Sally Fecto, senior vice president of field operations and a healthcare specialist at Harmony Healthcare International, in Topsfield, Massachusetts.

While there may be limited information in the medical record, especially if the resident is newly admitted, to choose ICD-10 code B20 (Human immunodeficiency virus [HIV] disease), the disease must be “active” and meet certain criteria. Otherwise, it would better fit under code Z21 (Asymptomatic human immunodeficiency virus [HIV] infection status), she says.

“CMS applies the 128 percent add-on to the per diem payment for patients with Acquired Immune Deficiency Syndrome (AIDS). Currently, the AIDS clinical indication is based on the ICD-10-CM coding of B20,” she explains.

“However, the ICD-10 B20 Code, unlike ICD-9 code 042, does not include ‘AIDS Like Syndrome’ among the symptoms applicable to this code, and therefore, payment for these patients would not include the AIDS per diem adjustment described above,” she says.

Understand: “Validation that patient qualifies for B20 is necessary to properly bill and the medical record demonstrates physician support for coding for the appropriate AIDS add-on,” Fecto says.

Understand How HIV and AIDS Differ

Regardless of whether you understand the clinical difference between HIV and AIDS, it’s crucial to know the Centers for Disease Control and Prevention (CDC)’s definition in order to code a resident’s condition accurately.

AIDS is the most severe stage of HIV and presents with the following, per the CDC:

1. CD4+ t-cell count below 200 cells/μL

2. CD4+ cell percentage of total lymphocytes of less than 15 percent

3. One of these defining illnesses:

• Candidiasis of bronchi, trachea, or lungs (see Fungal Infections)
• Candidiasis, esophageal (see Fungal Infections)
• Cervical cancer, invasive
• Coccidioidomycosis, disseminated (see Fungal Infections)
• Cryptococcosis, extrapulmonary (see Fungal Infections)
• Cryptosporidiosis, chronic intestinal (>1-month duration) (see Enteric Diseases)
• Cytomegalovirus disease (other than liver, spleen, or lymph nodes)
• Cytomegalovirus retinitis (with loss of vision)
• Encephalopathy, HIV-related (see Dementia)
• Herpes simplex: chronic ulcer(s) (>1-month duration) or bronchitis, pneumonitis, or esophagitis
• Histoplasmosis, disseminated (see Fungal Infections)
• Isosporiasis, chronic intestinal (>1-month duration) (see Enteric Diseases)
• Kaposi's sarcoma
• Lymphoma, Burkitt's
• Lymphoma, immunoblastic
• Lymphoma, primary, of brain (primary central nervous system lymphoma)
• Mycobacterium avium complex or disease caused by M. Kansasii, disseminated
• Disease caused by Mycobacterium tuberculosis, any site (pulmonary‡ or extrapulmonary†) (see Tuberculosis)
• Disease caused by Mycobacterium, other species or unidentified species, disseminated
• Pneumocystis carinii pneumonia
• Pneumonia, recurrent‡ (see Bacterial Infections)
• Progressive multifocal leukoencephalopathy
• Salmonella septicemia, recurrent (see Bacterial Infections)
• Toxoplasmosis of brain (encephalitis)
• Wasting syndrome caused by HIV infection

Anxiety, depression, dementia, and insomnia are also symptoms associated with AIDS, according to the University of California San Francisco’s website.

Note that all of the above conditions have their own, individual ICD-10 codes, as well.

Important: “Most people on antiretrovirals are consider symptomatic and would qualify for the B20 diagnosis. It is important to clarify with the physician,” says Ronald A. Orth, RN, NHA, CPC, post-acute care cirruculum designer at Relias Learning in Milwaukee, Wisconsin.

“Once a person is assigned B20, they are always B20, just an FYI. That is part of the ICD-10 Coding Guidelines,” Orth says.