HIV and AIDS, Understanding the Disease and Documentation Requirements

Spring has finally arrived across most of the country. The landscape is taking on the colors of blooming flowers and trees. This time of year signals new opportunities so let’s revisit one of the diagnoses that can be confusing to coders –  HIV and AIDS.  We will endeavor to better understand the disease process and requirements for documentation.  In turn, as coders, we will be better prepared to analyze record documentation, assign the accurate code and identify when a query is needed.

Human Immunodeficiency Virus (HIV), is a retrovirus that destroys the immune system, disabling the body’s ability to fight infections causing some lymphomas, other malignancies and opportunistic infections to grow.  The Official Coding Guidelines that we followed for coding HIV/ Acquired Immune Deficiency Syndrome (AIDS) in ICD-9-CM have not changed for ICD-10-CM. The only difference is that the codes have changed:

  • B20 – AIDS (previously 042)
  • Z21 – asymptomatic HIV status, HIV + (previously V08)

Regardless of whether a patient is newly diagnosed or has had previous admissions/encounters for HIV conditions, is irrelevant to the sequencing decisions.

  • Code only confirmed cases of HIV infection/illness – Inpatient & Outpatient
  • Chart documentation with qualified diagnoses such as “possible”, “probably”, “rule out”, “suspected” or “suspicion of” are never reported as AIDS (B20) – Inpatient or Outpatient

This is an exception to the rule on the Inpatient side!

  • In this context, “confirmation” does not require documentation of positive serology or culture for HIV; the provider’s diagnostic statement that the patient is HIV positive, or has an HIM-related illness is sufficient.

HIV Positive:  Code Z21

Used when the patient has never been diagnosed with AIDS or an AIDS-defining condition.  Also called “asymptomatic HIV” in ICD-10-CM.

  • Documentation coded as Z21 (not AIDS) – HIV positive, HIV +, HIV Infection, asymptomatic HIV, known HIV, HIV test positive. Do not use if the term “AIDS” is documented for the patient or the patient has any HIM-related illness or has a history of any HIV-related conditions.
  • A diagnosis of HIV + (Z21) is not the same as a diagnosis of HIV infection, symptomatic HIV/AIDS and AIDS (B20)

Diagnostic Criteria

For adults, adolescents and children >18 months of age, the CDC defines AIDS as an HIV-positive patient with any one of the following:

  • Current or prior diagnosis of an AIDS-defining condition


  • Current or prior CD4+ T-Lymphocyte count <200
  • The CD4 Count is a clinical indicator, however the provider MUST document AIDS, HIV related illness, etc., or a query is necessary.

Coding for HIV

For inpatient coding, the physician must state the diagnosis, and if not clearly documented, there is an opportunity to query for clarification.  For outpatient coding, it is often challenging for coders to determine if the patient is just HIV + (Z21) or if the patient has ever had an HIV-related illness (B20).  As of now, most outpatient coders do not have the capability to query for OP coding.  If the coder is unable to determine which the patient has based on the documentation provided, we should default to asymptomatic, rather than assigning the patient a diagnosis of AIDS.

Opportunistic Infections (OIs)

Healthy immune systems can be exposed to certain viruses, bacteria, or parasites and have no reaction to them.  However, people living with HIV/AIDS may have serious health threats from what are known as “opportunistic infections (OIs)”.  These infections attack the weakened immune system and can be life-threatening.  OIs are signs of a declining immune system.  Most life-threatening OIs occur when the CD4 count falls below 200 cells/mm3.  The CDC developed a list of more than 20 OIs that are considered AIDS-defining conditions. Patients having laboratory confirmed HIV infections and one or more of these OIs, will be diagnosed with AIDS regardless of the CD4 count.

Acquired Immunodeficiency Syndrome (AIDS)

AIDS is the final stage of human immunodeficiency virus (HIV) infection, stage 4 by the World Health Organization (WHO) criteria (2007) and stage 3 by Centers for Disease Control and Prevention (CDC) (2008) criteria or clinical categories B or C (CDC). AIDS code (B20) applies if AIDS has ever been previously diagnosed.  B20 must always be coded on every single subsequent encounter and never again code Z21 once AIDS is assigned.

  • Documentation coded as B20 –AIDS: HIC illness, HIV disease, ARC (AIDS – related complex), HIV symptomatic (any current AIDS-defining condition), HIV currently being treated for an HIV-related illness or is described as having any condition resulting from HIV + status, Acquired immune deficiency syndrome.
  • Once a patient has any HIV-related illness (OI0, every subsequent encounter should be coded as AIDS (B20)
  • Asymptomatic HIV (Z21) and inclusive HIV R75) are never reported once a patient has a confirmed diagnosis of AIDS.

Major AIDS-Related Conditions

Therapeutic Treatment

  • Antiretroviral treatment: (HAART) combination of drugs recommended
  • Pre-Exposure Prophylaxis (PrEP)
  • Post-Exposure Prophylaxis treatment for occupational exposure (PEP)

-Zidovudine (Retrovir, ZDZ,AZT) and Lamivudine (Epivir, 3TC) = Combivir

-Lamivudine (Epivir, 3TC) and Stavudine (Zerit, d4T)

-Didanosine (Videx, Videx EC, ddl) and Stavudine (Zerit,d4T)

  • Fulyzag for treatment of antiretroviral treatment induced diarrhea

A lot of information is included that I trust will clarify the assignment of HIV and AIDS as well as opportunities for query.   Take time to enjoy the Spring!


  1. Reference: Optum: Guide to Clinical Validation, Documentation and Coding (2014) p.34
  2. References: 2016 CDI Pocket Guide by R. D. Pinson, MD, FACP, CCS & C. L. Tang, RHIA, CCS. p.87, 88.
  3. Reference: Optum: Guide to Clinical Validation, Documentation and Coding (2014) p.30.
  4. Reference: U.S. Department of Health and Human Services. Potential Health Related Problems: Opportunistic Infections.  (2016).
  5. References: ICD-10-CM Official Guidelines and Reporting 2017 1.a.1.2


About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please comment below.


Beginning the New Year revisiting HIV/AIDS


“Think like a wise man but communicate in the language of the people.”

– William Butler Yeats – Irish poet


Just as cleansing snowfalls, cooler breezes and overcast skies accompany January into the New Year, revenue cycle change is sure to follow.   All of us play a valuable role in the success of increasing quality while decreasing cost as we analyze documentation and assign appropriate codes. Centers for Medicare and Medicaid Services (CMS) have provided the healthcare road map.  It is up to us to understand, communicate and carry out the plan.

As we march forward together, clear, concise, crisp, timely, communication is necessary.  The tasks are requiring more detail and the skills are becoming more defined.  We seek 100% accuracy and learn daily from feedback to be the best we can be.   Resolve in 2017 to thrive with the flow of information and ideas that catapult us into new revenue cycle horizons as we collaborate and communicate together.

Beginning the New Year revisiting HIV/AIDS:

  • Human immunodeficiency virus (HIV) is a virus transmitted through contact with bodily fluids (blood, semen, vaginal secretions, breast milk) containing infected plasma or cells. Being HIV positive from a blood test showing HIV antibodies is not the same as having human immunodeficiency virus disease (AIDS).  “Do not use [code Z21] Asymptomatic human immunodeficiency virus infection status if the term ‘AIDS’ is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV-positive status; use [code B20] human immunodeficiency virus disease in these cases.”
  • “When and OB patient is identified as having any HIV infection a [code from subcategory O98.7] is assigned with [code B20] assigned as an additional code. If an OB patient tests positive for HIV but has no symptoms and no history of an HIV infection, [codes O98.7- and Z21] are assigned rather than [code B20].”
  • 4 encounter for screening for HIV
  • 7 HIV counseling
  • 89 other problems related to lifestyle (high risk group for HIV infection)
  • 6 contact with and suspected to HIV
  • [Code B20] is NOT assigned when the diagnostic statement indicates that the infection is “suspected,” “possible,” “likely,” or “questionable”. This is an EXCEPTION to the general guideline that directs the coder to assign a code for a diagnosis qualified to ‘suspected” or “possible” as if it were established.  Confirmation in this case does not require documentation of a 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.  The provider should be asked to state the diagnosis in positive terms.
  • Once the patient is diagnosed as AIDS, HIV related disease [code B20], the patient is always reported as AIDS, HIV [code B20] related disease; not returned to the HIV status [code Z21]. “Patients with any known prior diagnosis of an HIV-related illness should be [coded to B20].  Once a patient has developed and HIV-related illness, the patient should always be assigned [code B20] on every subsequent admission/encounter.”

Additional Information:

  • Q: A patient with AIDS was treated in this hospital last year for AIDS-related histoplasmosis.  He is now admitted for acute nephritis.  In the record there is no clear statement that the nephritis is due to his AIDS.  What is the PDX?
  • A: Assign [N00.9] nephritis NOS as the PDX as there is no clear statement that the nephritis is an HIV-related disease.  The coder should not make such assumptions without clear indications within the record.  [Code B20] should be listed as an additional diagnosis. Coding Clinic 4Q 1994 p.35
  • Q: An AIDS patient is admitted for treatment of severe diarrhea and dehydration.  He is diagnosed to have Cryptosporidiosis with dehydration.  How should this be sequenced?
  • A: Assign [B20], [A07.2], [E86.0].  Coding Clinic 4Q 1997 p. 30,31
  • When documentation is unclear or conflicting, the provider must be queried for clarification.

I look forward to working alongside each of you, researching and supporting all the efforts that go into fulfilling a valued and respected profession, coder.  Greet each day with a smile of exhilaration and passion.

About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please email us at


An Ever-Changing Healthcare Environment

Across the country and around the world, healthcare organizations are feeling the winds of change.  Political, restructuring, budgetary, regulatory breezes all blow in different waves of change to our daily tasks as healthcare professionals that impact us.  Often I think of how as a child I feared change.  Whether it was moving to a new town, getting introduced to a new teacher, meeting new classmates, it wasn’t long until I realized the opportunity that change afforded me.  Then I wondered why I had spent so much energy on fear.

One of the biggest cheerleaders for change in my life is my mother who believes the reality of change is acceptance.  Before you can turn the corner for true change, you must accept the components of whatever is changing.  Many of us have planned, taught and worked with ICD-10 to the point of acceptance and we now are beginning to reap some of the rewards of specificity in reporting service line disease processes.

The Official Coding Guidelines implemented October 1, 2016, reiterated in Coding Clinic 4th Quarter 2016, included some changes that cannot be overwritten by facility-specific policy and warrant a closer look.

Zika virus infections (A92.5 Zika virus disease) requires the provider document a confirmation statement that the patient zika mosquitohas Zika virus infection.  Possible, probable, suspected, terminology do not apply.  Much like HIV that must be confirmed before coding, avian flu must be confirmed before coding, so now is true for Zika virus infection.  Lots of people are being tested for such viruses, but only those confirmed by the provider are coded.  Non-confirmed cases may be coded to Z20.828 Contact with and suspected exposure to other viral communicable diseases.


  • 84 long term use of oral hypoglycemic drugs
  • – or I51.4- – I51.9 included in the I11 category of hypertensive heart disease
  • Use additional code from category I50 heart failure for type of heart failure
  • Sequence according to the circumstances of admission/encounter
  • I12 category represents Hypertensive CKD
  • Use additional code from category N18 for stage of CKD
  • I16 hypertensive crisis (urgency, emergency), category I10 – I15 also
  • STEMI/NSTEMI meeting secondary diagnosis criteria may be assigned within 4 weeks of the diagnosis when readmitted or transferred
  • Pressure ulcers that heal during a visit, assign the code of site/stage upon admission
  • Evolving pressure ulcers, assign one code for site and stage on admission (POA Y) and another code for site and stage for the same ulcer that progressed during the stay ( POA N)
  • Assign O09 supervision of high-risk pregnancy only during the prenatal period, if there are no applicable complication codes form Chapter 15, O80 is assigned
  • Assign the reason that prompted the admission when delivery occurs as the PDX
  • When multiple conditions are present at the time of admission on a delivery encounter; assign the PDX as the one that relates to the delivery.
  • Observation and evaluation of newborns for suspected condition not found assign Z05 (ie. Ruled out sepsis)
  • Poisoning when the intent is not known defaults to accidental intent, only assign undetermined when the documentation specifies the intent cannot be determined
  • Category Z3A is only applicable to deliveries, not applicable for abortion, termination of pregnancy or postpartum conditions.
  • A condition that the entire code component is not POA, is assign N, (acute exacerbation of COPD, however, the exacerbation occurred on day three of the hospital stay) The COPD was POA, however, the exacerbation was POA = N so the code is assign POA = N

The more we revisit these changes and put them into practice, the easier the changes are to accept and soon they become the new reality.  As we approach the season that reminds us to be thankful for all our blessings, let us appreciate the opportunities that change presents and work together to be the very best we can be.

About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please email us at

What’s up “with” Diabetic Coding?

Responding to coder questions has always been one of my great joys.  The challenge of searching for the underlying cause or the analysis of a detailed operative note is second only to a Dr. Seuss favorite with my Grands.  Lately, diabetic coding has been a frequent topic for clarification.

According to the American Diabetes Association,“29.1 million Americans have been diagnosed with diabetes with another 86 million identified with pre-diabetes.”  The manifestations and associated conditions are staggering, as this disease impacts many body systems.  In ICD-9-CM code assignment with the designation of primary or secondary whether type I or II, controlled, uncontrolled and with a documented association of manifestations common to diabetes was the guidance. ICD-10-CM implementation eliminated the controlled and uncontrolled designation, opting for a more robust manifestation instruction.

The American Hospital Association (AHA) Coding Clinic publications for first quarter 2016, again second quarter 2016 reiterate the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 I.A.15 which says:

“With”  the word “with” should be interpreted to mean “associated with” or “due to” when it appears in the code title, the Alphabetic Index, or an instructional note in the Tabular List.  The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.  These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must like the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.”

As coders plunge into their daily coding process, there remain areas of concern in complying with the instruction that as written seems so clear.  In the setting of a type II diabetic patient presenting with nausea and vomiting, gastric emptying studies support the diagnosis of gastroparesis the diagnosis code assigned would be E11.43.  The proximity of the documentation in the record of the two conditions (diabetes type II) and (Gastroparesis) have no bearing on the expectation to assign one code, assuming the relationship between the diabetes type II and the gastroparesis.

The same is true for CKD, foot ulcer, gangrene, and the list goes on as the coder references the Index “Diabetes, diabetic (Mellitus)(sugar) “with” or enters the key word “diabetes” in the encoder.  Recent coder questions include the diagnosis of cataract.  When the provider has not documented the type of cataract, (nuclear sclerosis, age-related, etc.) the coder is instructed to assume a link between the diabetes and cataract, reporting as diabetic cataract.  This may be an area of concern for some facilities as their statistical analysis will shift from an “H” diagnosis in Chapter 5 diseases of the eye to an “E” diagnosis in Chapter 4 endocrine diseases.  In talking with a local ophthalmologist, this raised awareness for him as he shared he has many diabetic patients that he may perform cataract surgery that have no relationship between the two conditions.  It is important to inform the providers as guidelines change that may impact their patient population data so they understand the need for the appropriate level of specificity documentation.

Osteomyelitis is also causing some eyebrow rising among coders.  The coding book Index, Diabetes “with” includes osteomyelitis “E11.69”.  In the coding book Index, Diabetes Type I or Type II “with” does not include osteomyelitis.  So, what’s a coder to do?  The answer was provided today in the AHIMA October 15, 2016 Conference.  Everywhere in the ICD-10 CM index that “with” is a part of the indexed condition, the link between the condition referenced by the index and the “with” condition is to be made unless the provider has documented the referenced condition is not due to the “with” condition or is due to another condition.  That includes osteomyelitis in a diabetic patient.  Just to be sure we are clear, additional examples including osteomyelitis will be included in the Coding Clinic 4th Quarter 2016.

As we continue to work with providers with regard to their documentation it is important to share with them how their patient is reflected in coding as many of them are unaware of coding guidelines.  Documentation matters now more than ever.

About the Author

Marie Thomas holds a Masters Healthcare Administration from Pfeiffer University, Charlotte, NC, and a Bachelor of Science in Healthcare Administration from Pfeiffer University. Marie has furthered her career education by becoming an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador as well as earning the RHIT, CCS, CCDS, and CPC-H credentials. For more information please email us at

A Fresh Look at Obstetric Coding