Advice for Coding and Documenting HIV

National HIV Testing Day is June 27.

Wednesday is National HIV Testing Day—a day designated to highlight the importance of testing in detecting, treating, and preventing human immunodeficiency virus (HIV) infection.

This special day is designed to encourage people to get tested for HIV, know their status, and get linked to care and treatment if they have HIV. This year’s theme, Doing It My Way, Testing for HIV, reminds us that each person has his or her own reasons why they test for HIV, and their own unique ways of doing so.

About 1.1 million people in the United States have HIV, and one in seven of them don’t know it. Many people have HIV for years before they get a diagnosis. For those living with undiagnosed HIV, testing is the first step in maintaining a healthy life and reducing HIV transmission. Thus, awareness of HIV infection through HIV testing is the first step to social services that improve life quality and length of survival.

The Centers for Disease Control and Prevention (CDC) recommend to healthcare providers that they:

  • Routinely provide HIV testing to all people ages 13 to 64, in accordance with CDC guidelines.
  • Screen all teens and adults for HIV risk and test people at high risk at least once a year. This includes some gay and bisexual men who may benefit from more frequent testing (for example, every three to six months).
  • Start people on HIV treatment as quickly as possible after diagnosis.
  • Discuss prevention tools with patients. Provide or refer them to prevention services, including pre-exposure prophylaxis (PrEP) and services for people who inject drugs.

You can locate a HIV testing center near you by using this CDC link: https://www.cdc.gov/hiv/library/awareness/testingday.html.

Simply enter your ZIP code or city and it will direct you to a testing center near you. In addition, the CDC’s guidelines for HIV testing of serum and plasma specimens are available online at https://www.cdc.gov/hiv/guidelines/testing.html.

Clinical coding of HIV in ICD-10-CM brings you to Chapter 1 for Certain Infectious and Parasitic Diseases, code range A00-B99, and then to the three-character code B20, Human immunodeficiency virus (HIV)

When coding, be sure to note the includes:

  • Acquired immune deficiency syndrome (AIDS)
  • AIDS-related complex (ARC)
  • HIV infection, symptomatic

Type 1 excludes:

  • Asymptomatic human immunodeficiency virus (HIV) infection status (Z21)
  • Exposure to HIV virus (Z20.6)
  • Inconclusive serologic evidence of HIV (R75

Additional instructional notes at the B20 code level are:

  • Use Additional: Code(s) to identify all manifestations of HIV infection
  • Code First: Human immunodeficiency virus (HIV) disease complicating pregnancy, childbirth, and the puerperium, if applicable (O98.7-)

Also, check out ICD-10-CM code Z11.4, Encounter for screening for human immunodeficiency virus (HIV). Remember that “screening” is the testing for a disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided to those who test positive for the disease.

With national awareness of HIV testing being promoted this week, it’s a great time for coding and CDI professionals to review the coding of HIV.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS

Gloryanne is an HIM coding professional and leader with more than 40 years of experience. She has an RHIA, CDIP, CCS, and a CCDS. For the past six years she has been a regular speaker and contributing author for ICD10monitor and Talk Ten Tuesdays. She has conducted numerous educational programs on ICD-10-CM/PCS and CPT coding and continues to do so. Ms. Bryant continues to advocate for compliant clinical documentation and data quality. She is passionate about helping healthcare have accurate and reliable coded data.

Related Stories

How to Report New Code Category W44

How to Report New Code Category W44

One of the goals of medical coding is documenting encounter notes to the highest degree of specificity. ICD-10-CM had some existing codes for documenting foreign

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →