ICD-10 Coding for HIV Infection(B20, Z21)
Complete ICD-10-CM coding and documentation guide for HIV Infection. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to HIV Infection
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 the patient has symptomatic HIV or a history of HIV-related illness. |
|
| Z21 | Asymptomatic human immunodeficiency virus [HIV] infection status | Use when the patient is HIV positive but asymptomatic and without history of related conditions. |
|
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 symptomatic HIV
Essential facts and insights about HIV Infection
Primary ICD-10-CM Codes for human immunodeficiency virus infection
Decision Criteria
clinical Criteria
- Presence of AIDS-defining condition or history of such conditions.
documentation Criteria
- Provider documentation explicitly states 'AIDS' or 'HIV disease'.
Applicable To
- AIDS
- HIV disease
- HIV with related conditions
Excludes
- Asymptomatic HIV infection status (Z21)
Clinical Validation Requirements
- Provider documentation of AIDS or HIV-related condition
- CD4 count <200 cells/mm³
- Presence of opportunistic infections
Code-Specific Risks
- Incorrectly coding asymptomatic patients with B20
- Failure to document HIV-related conditions
Coding Notes
- Once B20 is assigned, it is used permanently even if the patient becomes asymptomatic.
Z21 - Asymptomatic human immunodeficiency virus [HIV] infection status
Use when the patient is HIV positive but asymptomatic and without history of related conditions.
Applicable To
- HIV positive without symptoms
Excludes
- HIV disease (B20)
Clinical Validation Requirements
- Provider documentation of asymptomatic HIV status
- No history of HIV-related conditions
Coding Notes
Z21 should not be used if the patient has ever had an HIV-related condition.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting HIV Infection to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code B20.
Impact
Clinical: Inaccurate treatment plans., Regulatory: Potential audit issues., Financial: Incorrect reimbursement rates.
Mitigation Strategy
Regularly review and update patient records., Ensure clear documentation of any new HIV-related conditions.
Impact
Reimbursement: Incorrect coding can lead to lower reimbursement., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Assign B20 if there is any history of HIV-related conditions.
Impact
Using Z21 for patients with a history of HIV-related conditions.
Mitigation Strategy
Ensure thorough review of patient history before coding.
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 HIV Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for HIV Infection
Use these documentation templates to ensure complete and accurate documentation for HIV Infection. These templates include all required elements for proper coding and billing.
HIV Management in Primary Care
Specialty: Internal MedicineRequired Elements
- HIV status
- History of HIV-related conditions
- Current symptoms
- Antiretroviral therapy
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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