ICD-10 Coding for History of Human Immunodeficiency Virus(B20, Z21)
Complete ICD-10-CM coding and documentation guide for History of Human Immunodeficiency Virus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Human Immunodeficiency Virus
B20Primary Range
Human immunodeficiency virus [HIV] disease
Used for patients with a history of HIV-related illness or AIDS.
Asymptomatic human immunodeficiency virus [HIV] infection status
Used for patients who are HIV positive without any history of HIV-related illness.
Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium
Used for coding HIV in pregnant patients.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| B20 | Human immunodeficiency virus [HIV] disease | Use when there is a history of HIV-related illness, regardless of current symptoms. |
|
| Z21 | Asymptomatic human immunodeficiency virus [HIV] infection status | Use when the patient is HIV positive but has never had an HIV-related illness. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for history of HIV
Essential facts and insights about History of Human Immunodeficiency Virus
Primary ICD-10-CM Codes for history of human immunodeficiency virus
Decision Criteria
clinical Criteria
- History of opportunistic infections or AIDS-defining conditions.
Applicable To
- AIDS
- HIV disease
Excludes
- Asymptomatic HIV infection status (Z21)
Clinical Validation Requirements
- CD4 count <200 cells/mm³
- History of opportunistic infections
Code-Specific Risks
- Incorrectly using Z21 for patients with past HIV-related illness.
Coding Notes
- Once B20 is assigned, it is used for all future encounters.
Z21 - Asymptomatic human immunodeficiency virus [HIV] infection status
Use when the patient is HIV positive but has never had an HIV-related illness.
Applicable To
- HIV positive without symptoms
Excludes
- HIV disease (B20)
Clinical Validation Requirements
- No history of opportunistic infections
Coding Notes
Z21 should not be used if the term 'AIDS' is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Human Immunodeficiency Virus to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code B20.
Impact
Clinical: Inaccurate patient history., Regulatory: Non-compliance with coding standards., Financial: Potential loss of reimbursement.
Mitigation Strategy
Regularly update patient history., Use standardized templates for documentation.
Impact
Reimbursement: Incorrect coding can lead to improper DRG assignment., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Always use B20 if there is any history of HIV-related illness.
Impact
Using Z21 for patients with a history of HIV-related illness.
Mitigation Strategy
Educate coders on the importance of historical documentation.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Human Immunodeficiency Virus, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Human Immunodeficiency Virus
Use these documentation templates to ensure complete and accurate documentation for History of Human Immunodeficiency Virus. These templates include all required elements for proper coding and billing.
HIV Progress Note
Specialty: Infectious DiseaseRequired Elements
- Current CD4 count
- Viral load
- History of opportunistic infections
- Current ART regimen
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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