Guidelines for HIV coding

Chapter 1: Certain Infectious and Parasitic diseases (A00-B99)

Human Immunodeficiency virus (HIV) Infections

B20 Human immunodeficiency virus (HIV) disease (symptomatic)

R75 Inconclusive laboratory evidence of human immunodeficiency virus (HIV)

Z20.6 Contact with and exposure to human immunodeficiency virus (HIV)

Z11.4 Encounter for screening for human immunodeficiency virus (HIV)

Z71.7 human immunodeficiency virus [HIV] counseling

Z21 Asymptomatic human immunodeficiency virus (HIV) infection status

“Confirmation” does NOT require documentation for positive serology or culture for HIV; the provider’s diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient.  Once a patient is diagnosed with B20, they should never be assigned R75 or Z21.

Sequencing of HIV Codes

B20 should be sequenced as the first-listed diagnosis when patient is treated for an HIV related condition. Any non-related conditions get sequenced following the related condition.

When patient is treated for unrelated condition, the diagnosis code for the unrelated condition is listed first, followed by the HIV related code – either B20 for symptomatic patient or Z21 for an asymptomatic patient.

Asymptomatic Human Immunodeficiency Virus

Z21 Asymptomatic human immunodeficiency virus (HIV) infection status, is used when patient is listed as being “HIV positive,” “known HIV,” “HIV test positive,” without documentation of symptoms. IF the term “AIDS” is used, do not use Z21. Use B20.

Z21 is ued to report a patient diagnosed with HIV positive status but without opportunistic infections.  One a patient has a first opportunistic infection, they as assigned B20 thereafter.  Codes B20 and Z21 are never to appear on the same record.

Pregnancy, childbirth or the puerperium

If the patient presents for care because of an HIV-related illness, they should receive the diagnosis code of O90.7-Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium followed by B20 and the code for the HIV-related illness. Asymptomatic HIV infection status should receive codes of O98.7-and Z21.

When a patient has HIV and is pregnant, codes from chapter 15 - Pregnancy, childbirth or the puerperium are sequenced first.

Encounters for Testing for HIV

Z11.4 Encounter for screening for human immunodeficiency virus [HIV] Additional codes may be used for any associated high-risk behavior.   When a patient returns for results of their HIV testing and the results are negative, use code Z71.7 Human immunodeficiency virus [HIV] counseling.