Advice for Coding and Documenting HIV

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Original story posted on: June 25, 2018

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.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Gloryanne Bryant is an independent health information management (HIM) coding compliance consultant with more than 40 years of experience in the field. She appears on Talk Ten Tuesdays on a regular basis and is a member of the ICD10monitor editorial board.

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