Pathology/Lab Coding Alert

Question: A physician client ordered an HIV test for a patient with “high risk sexual behavior,” stating that he was concerned that the patient had been exposed to HIV. What diagnosis codes should we report?

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Answer: Because the physician doesn’t document a condition or symptom, you should use a “Z” code as the ordering diagnosis. These codes document factors influencing health status and contact with health services.

In this case, you should document the high risk sexual behavior using one of the following codes:

• Z72.51 — High risk heterosexual behavior
• Z72.52 — High risk homosexual behavior
• Z72.53 — High risk bisexual behavior

Based on the suspicion of exposure to HIV through sexual contact, you should also report Z20.2 (Contact with and [suspected] exposure to infections with a predominantly sexual mode of transmission) as a secondary diagnosis code.

Remember: “Z” codes are allowed as primary codes when they are the best description for the main reason a patient is being seen, according to Judy Adams, RN, BSN, HCS-D, AHIMA approved ICD-10-CM Trainer with Adams Home Care Consulting in Asheville, N.C.