HIV coding is some time become a really complicated if we couldn’t judge the real condition of disease like patient is only a carrier or suffering with AIDS. Proper documentation is required for justification of condition which should be coded.
For a right coding we should know about the differentiation between AIDS and HIV.
AIDS is not a virus but a set of symptoms caused by the HIV virus. A person is said to have AIDS when their immune system is too weak to fight off infection, and they develop certain defining symptoms and illnesses. This is the last stage of HIV, when the infection is very advanced, and if left untreated will lead to death.
HIV is a virus that attacks the immune system, which is our body’s natural defence against illness. The virus destroys a type of white blood cell in the immune system.
CODE ONLY CONFIRMED CASES
Only confirmed cases should be code. If documents context like HIV positive, AIDS or HIV related problems then it will be considered as confirmed diagnosis.
SEQUENCING OF HIV CODES
If patient is newly diagnosed
Sequencing rule is not apply on previous diagnosis or admission.
If patient admitted for HIV related problem;
Principle diagnosis for HIV B20 + Additional Diagnosis related Disease or diagnosis.
HIV related diagnosis: Tuberculosis (TB), Cytomegalovirus infection, Candidiasis, Cryptococcal meningitis, Toxoplasmosis, Kaposi’s sarcoma, Kidney disease etc.
EXAMPLE: Mr John came to the hospital with severe respiratory infection. Dr. George admitted him in hospital and concluded that John is HIV patient and due to weak immune power, now he suffered with severe infection in lungs.
CODE : B20 + additional diagnosis for respiratory infection
If patient with HIV admitted for some unrelated condition
Principle diagnosis for unrelated Disease or diagnosis + Additional Diagnosis HIV B20
EXAMPLE: Mr Jack is a HIV patient and met an road accident and injured badly. Physician admitted him in hospital and found his left knee and left shoulder fractured. Code this scenario.
CODE : left knee and shoulder fracture + B20
When the patient is HIV positive but no visible symptoms are present that condition known as asymptomatic HIV. Asymptomatic HIV can be coded as Z21. If documents states like ‘HIV positive’, ‘HIV test positive’ or ‘known HIV’ without ant symptoms then code condition as Z21.
If document states like AIDS then never use Z21.
Inconclusive HIV serology
Inconclusive mean when result is not concluded and no definitive diagnosis is found then condition can be coded as R75 .
Previously diagnosed HIV related illness
If patient previously diagnosed with any HIV related illness, then every subsequent visit should be coded with B20. Z21 and R75 never assigned.
Pregnancy related with HIV infection
If pregnant mother is HIV positive during pregnancy or childbirth. Condition can be coded as:
Principle Diagnosis O98.7 + B20 + Additional diagnosis related illness
Principle Diagnosis O98.7 + Z21 + Additional diagnosis related illness
Encounter for testing for HIV
If patient is seen for HIV status:
Z11.4 : Encounter for screening for human immunodeficiency virus [HIV].
Z71.7: Human immunodeficiency virus [HIV] counselling