ICD-10 Coding for HIV Positive Status(B20, Z21)
Complete ICD-10-CM coding and documentation guide for HIV Positive Status. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to HIV Positive Status
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 an HIV-related condition or AIDS is documented. |
|
| Z21 | Asymptomatic human immunodeficiency virus [HIV] infection status | Use when the patient is HIV positive but asymptomatic and has no history of HIV-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 HIV positive
Essential facts and insights about HIV Positive Status
Primary ICD-10-CM Codes for human immunodeficiency virus positive
Decision Criteria
clinical Criteria
- Presence of AIDS-defining conditions
documentation Criteria
- Explicit mention of AIDS or HIV-related condition
Applicable To
- AIDS
- HIV with related conditions
Excludes
- Asymptomatic HIV infection status (Z21)
Clinical Validation Requirements
- CD4 count <200 cells/mm³
- Presence of opportunistic infections
- HIV RNA >100,000 copies/mL
Code-Specific Risks
- Incorrectly coding asymptomatic patients as B20
- Missing documentation of related conditions
Coding Notes
- Once B20 is assigned, it is used for all subsequent encounters.
Z21 - Asymptomatic human immunodeficiency virus [HIV] infection status
Use when the patient is HIV positive but asymptomatic and has no history of HIV-related conditions.
Applicable To
- HIV positive without symptoms
Excludes
- HIV disease (B20)
Clinical Validation Requirements
- CD4 count >200 cells/mm³
- Undetectable viral load
- No history of opportunistic infections
Coding Notes
Z21 is not used if the patient is on ART or has a history of HIV-related conditions.
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 Positive Status 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 management., Regulatory: Non-compliance with coding standards., Financial: Potential loss of reimbursement.
Mitigation Strategy
Regularly review patient history for any new HIV-related conditions., Ensure documentation reflects current clinical status.
Impact
Reimbursement: Incorrect coding may lead to lower reimbursement., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Assign B20 if the patient has any history of HIV-related conditions.
Impact
Using Z21 for patients with a history of HIV-related conditions.
Mitigation Strategy
Implement regular training on HIV coding guidelines.
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 Positive Status, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for HIV Positive Status
Use these documentation templates to ensure complete and accurate documentation for HIV Positive Status. These templates include all required elements for proper coding and billing.
HIV Positive Patient on ART
Specialty: Infectious DiseaseRequired Elements
- HIV status
- CD4 count
- Viral load
- ART regimen
- History of HIV-related conditions
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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