Maximizing Billing and Coding for HIV Testing

Part 3 of 4: HIV/AIDS Care Diagnosis Codes

Presenter: Stacey L. Murphy, MPA, RHIA, CPC

AHIMA Approved ICD-10-CM/ICD-10-CM Trainer
14 December 2015
 Stacey L. Murphy, Presenter
• 30 years of practice management, physician credentialing/re-
credentialing, contract management, and coding and clinical
documentation experience.

• Certified Professional Coder (CPC) credentialed by the American

Academy of Professional Coders since 1998 and a Registered Health
Information Administrator (RHIA) since 2011 credentialed by the American
Health Information Management Association (AHIMA). She is also
credentialed by AHIMA as an ICD-10-CM/ICD-10-PCS Approved Trainer.

• As the Chief of Health Information Management (HIM) working for the

Veterans Administration, she is currently responsible for ensuring that all of
the HIMS coding staff are properly trained and ready for the ICD-10
coding implementation. She also ensures that documentation and coding
information is disseminated timely to clinicians and other administrative
staff at the Veterans Administration.
 Disclaimer
The documentation and coding information was produced as an
informational reference for the HealthHIV organization. No
representation, warranty, or guarantee that compilation of this
information is error-free and we bear no responsibility or liability for the
results or consequences of the use of this material. Although every
reasonable effort has been made to assure the accuracy of the
information contained in the presentation, the information is
constantly changing and it is the sole responsibility of the clinician to:
• Ensure that best practices in patient care are met.
• Remain abreast of each health plans regulatory requirements since
regulations, policies and/or coding guidelines cited in this presentation
are subject to change without further notice.
• Ensure that every reasonable effort is made to adhere to applicable
regulatory guidelines within their respective jurisdiction.
 Learning Outcomes
• Brief overview of ICD-9-CM codes and its phase out
• Identify the various ICD-10-CM codes that describe
AIDS/HIV patient care
– Identify the ICD-10-CM coding guidelines for
AIDS/HIV patient care
– Explain the differences between the various codes
• Explain the diagnosis code selection process
• Explain the importance of proper code sequencing
 Acronyms Used
• AMA - American Medical Association
• ARC - AIDS Related Complex
• CMS - Centers for Medicare and Medicaid Services
• CDC - Centers for Disease Control
• Dx – Diagnosis
• HEDIS – Healthcare Effectiveness Data and Information Set
• HIPAA – Health Insurance Portability and Accountability Act
• HIV 1 - Human Immunodeficiency Virus 1
• HIV 2 - Human Immunodeficiency Virus 2
• OI - Opportunistic Infection
• ICD-9-CM - International Classification of Diseases, 9th Revision, Clinical
Modification
 Acronyms Used (cont.)
• ICD-10-CM – International Classification of Diseases, 10th Revision, Clinical
Modification

• ICD-10-PCS – International Classification of Diseases, 10th Revision,

Procedure Coding System

• PDx - Principal Diagnosis

• PrEP – Pre-exposure Prophylactics

• PEP – Post exposure Prophlyactics

• SDx - Secondary Diagnosis

• QARR – Quality Assurance Reporting Requirements

• PQRS – Physician Quality Reporting System

• WHO - World Health Organization

 ICD-9 Code System
ICD-9-CM - International Classification of
Diseases, 9th Revision Clinical Modification
• ICD-9 codes developed by the World Health
Organization in 1948
• ICD-9 codes revised and published for use in the U.S. in
1979 for morbidity and mortality statistics
• CMS mandated the use of ICD-9 codes on all claims
since October 1988
– CMS revised these mandates to reflect “mandatory” correct reporting
of ICD-9 codes on all claims

• ICD-9 codes describe medical conditions (diseases),

injuries and poisoning
 ICD-9 Phased Out
The ICD-9 coding system phased out
October 1, 2015 and replaced with two new
Coding Systems: ICD-10-CM & ICD-10-PCS
• The ICD-9 coding system is outdated and does not
reflect emerging technology
• The ICD-10 coding system is consistent with changes in
health care and provides more codes that reflect
emerging technology
– ICD-10-CM codes are used to report medical conditions
– ICD-10-PCS codes are reported on inpatient hospital
(institutional) claims only to reflect the facility bill
 Phased Out (cont.)
• Continue reporting CPT & HCPCS codes for services
rendered by physicians
• Continue reporting ICD-9-CM codes for any backlog
services rendered through September 30, 2015
– Claims submitted with ICD-10 codes for services
rendered now through September 30, 2015 will be
denied
• Report ICD-10-CM codes for services rendered on or
after October 1, 2015
– Claims submitted with ICD-9-CM codes for services
rendered on or after October 1, 2015 will be denied
 What Has Changed?
ICD-9-CM DIAGNOSIS CODES
Volumes (1 & 2)
ICD-10-CM CODES
Approximately 13,000 codes Approximately 70,000 codes
3- 5 characters in length Up to 7 characters in length
• First character always alpha (except letter U)
First character is alpha or numeric
• Not case sensitive
(Example: Dx 042 - AIDS, HIV+ Dx V08 – HIV+)
(Example: Dx B20 – AIDS, Dx Z21 – HIV+)
• Second character always numeric
Characters 2-5 are always numeric
• 3-7 character alpha or numeric
Use of decimal point after 3rd character Use of decimal point after 3rd character
Limited inclusion of co-morbidities, complications, Inclusion of co-morbidities, complications,
severity, manifestation, risks, sequelae or other severity, manifestation, risks, sequelae or other
disease related parameters disease related parameters
No distinction of laterality (left/right/bilateral) Includes laterality as appropriate
Includes initial vs. subsequent episodes as
No distinction of initial or subsequent episodes
appropriate
Combination codes are limited Includes numerous combination codes
Use of dummy place holder “x” as applicable for
Code expansion availability very limited
future code expansion
 What Has Changed? (2)
– New/revised terminology – Limited use of NEC and
NOS
– Increase in number of
available codes – ICD-10-CM comprises of
21 chapters vs 17
– New codes that chapters in ICD-9-CM
reflect laterality – Room for future code
– Increase in episode expansion
of care codes – Most significant changes
– Increased use of affect:
specificity – Musculoskeletal
– Increased use of System
combination codes – Injury & Poison
section
 What Has Changed? (3)
– Supplementary classification section (V codes
and E codes in ICD-9-CM) no longer exists
– Now part of the main section in ICD-10 (tabular
index)
– V codes in ICD-9 are now Z codes in ICD-10
– External cause ICD-9 codes (E codes) are now V, W,
X and Y codes in ICD-10
 What Has Changed? (4)
Code Expansion
– Addition of dummy placeholder “x” for certain
codes to:
– Fills empty characters for codes that require 6th and 7th
character designation to provide additional details for:
– Inclusion of trimesters in Obstetrics
– Diabetes (now reflects ADA classifications)
– Substance abuse
– Postoperative complications
– Injuries (Gustilo fracture classification and concussions)
– External causes of injuries
 What Has Changed? (5)
Code Expansion
– Remember there are 2 different types of 7th character
designations in ICD-10:
– √7th This symbol indicates that the code requires a
7th character that typically describes episode of
care
– √x7th This symbol indicates that the code requires a
7th character following the dummy placeholder x.
Codes with fewer than six characters that require a
7th character must contain placeholder “x” to fill in
the empty character(s).
 What Has Changed? (6)
• Some codes now require the following 7th
character values:
– Disease of the musculoskeletal system
(pathological fractures)
– Injury, Poisoning and Certain Other
Consequences of External Causes
7th Digit Description Coding Guidelines
Patient receiving active treatment i.e.
A Initial encounter surgery, ED, Physician clinic/Office visit
Patient completes active treatment and
D Subsequent encounter presents for routine follow
Patient follow up for sequela or residual
S Sequela effect
 What Has Changed? (7)
– New/revised coding guidelines and instructions
– Designation of EXCLUDES1 and

EXCLUDES2 notes

– Excludes1: Codes stated as Excludes1, never

reported with selected code
– Excludes2: Condition excluded is not part of the
condition represented by the selected code
 What Has Changed? (8)
Chapter Chapter Name
Chapter 1 Certain infectious and parasitic diseases (A00-B99)
Chapter 2 Neoplasms (C00-D49)
Diseases of the blood and blood-forming organs and certain disorders
Chapter 3
involving the immune mechanism (D50-D89)
Chapter 4 Endocrine, nutritional and metabolic diseases (E00-E89)
Mental, Behavioral and Neurodevelopmental disorders
Chapter 5
(F01-F99)
Chapter 6 Diseases of the nervous system (G00-G99)
Chapter 7 *Diseases of the eye and adnexa (H00-H59) – NEW SECTION
*Diseases of the ear and mastoid process (H60-H95) –
Chapter 8
NEW SECTION
Chapter 9 Diseases of the circulatory system (I00-I99)
Chapter 10 Diseases of the respiratory system (J00-J99)
Chapter 11 Diseases of the digestive system (K00-K95)
Chapter 12 *Diseases of the skin and subcutaneous tissue (L00-L99)

*Signification changes in this section reflect laterality and/or episode of care

 What Has Changed? (9)
Chapter Chapter Name
*Diseases of the musculoskeletal system and connective tissue
Chapter 13
(M00-M99)
Chapter 14 Diseases of the genitourinary system (N00-N99)
Chapter 15 Pregnancy, childbirth and the puerperium (O00-O9A)
Chapter 16 Certain conditions originating in the perinatal period (P00-P96)
Congenital malformations, deformations and chromosomal
Chapter 17
abnormalities (Q00-Q99)
Symptoms, signs and abnormal clinical and laboratory findings,
Chapter 18
not elsewhere classified (R00-R99)
*Injury, poisoning and certain other consequences of external
Chapter 19
causes (S00-T88)
Chapter 20 *External causes of morbidity (V00-Y99) – NEW SECTION
Factors influencing health status and contact with health services
Chapter 21
(Z00-Z99) – NEW SECTION

*Signification changes in this section reflect laterality and/or episode of care

The Official ICD-10-CM Coding Guidelines

According to the ICD-10-CM Official Coding

Guidelines, ICD-10-CM code B20 includes the
following terms:
– Acquired immune
deficiency syndrome
– HIV infection, symptomatic
– Acquired
– HIV 1
immunodeficiency
– Pre-AIDS
syndrome
– Prodromal AIDS
– AIDS
– HIV Disease
– AIDS-like syndrome
– AIDS-related complex
The Official ICD-10-CM Coding Guidelines (2)

1. Chapter 1: Infectious and Parasitic Diseases

(A00-B99)
a. Human Immunodeficiency Virus (HIV) Infections (B20)
1) Code only confirmed cases
Code only confirmed cases of HIV infection/illness. This is an
exception to the hospital inpatient guideline Section II, H.

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 HIV-related illness
is sufficient.
The Official ICD-10-CM Coding Guidelines (3)

2) Selection and sequencing of HIV codes

(a) Patient admitted for HIV-related condition

If a patient is admitted for an HIV-related condition, the principal

diagnosis should be B20, followed by additional diagnosis codes for
all reported HIV-related conditions.

(b) Patient with HIV disease admitted for unrelated condition

If a patient with HIV disease is admitted for an unrelated condition

(such as a traumatic injury), the code for the unrelated condition
(e.g., the nature of injury code) should be the principal diagnosis.
Other diagnoses would be B20 followed by additional diagnosis
codes for all reported HIV-related conditions.
The Official ICD-10-CM Coding Guidelines (4)

(c) Whether the patient is newly diagnosed

Whether the patient is newly diagnosed or has had previous

admissions/encounters for HIV conditions is irrelevant to the
sequencing decision.

(d) Asymptomatic human immunodeficiency virus

Z21, Asymptomatic human immunodeficiency virus [HIV] infection, is

to be applied when the patient without any documentation of
symptoms is listed as being “HIV positive,” “known HIV,” “HIV test
positive,” or similar terminology. Do not use this code 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 B20 in these cases.
The Official ICD-10-CM Coding Guidelines (5)

(e) Patients with inconclusive HIV serology (R75)

Patients with inconclusive HIV serology, but no definitive diagnosis or
manifestations of the illness, may be assigned code R75, inconclusive
serologic test for Human Immunodeficiency Virus [HIV].

(f) Previously diagnosed HIV-related illness

Patients with any known prior diagnosis of an HIV-related illness should
be coded to B20. Once a patient has developed an HIV-related
illness, the patient should always be assigned code B20 on every
subsequent admission/encounter. Patients previously diagnosed with
any AIDS/HIV illness (B20) should never be assigned to R75 or Z21
(HIV+).
The Official ICD-10-CM Coding Guidelines (6)

(h) Encounters for testing for HIV (Z11.4)

If a patient is being seen to determine his/her HIV status, use code

Z11.4, Encounter for screening for human immunodeficiency virus
(HIV). Use additional codes for any associated high risk behavior
(Z72.-).

If a patient with signs or symptoms is being seen for HIV testing, report
the signs and symptoms also. An additional counseling code, Z71.7,
Human immunodeficiency virus (HIV) counseling may be used if
counseling is provided during the encounter for the test.

When a patient returns to be informed of his/her HIV test results and

the test results are negative, use code Z71.7, Human
immunodeficiency virus (HIV) counseling.

If the results are positive, see previous guidelines and assign codes as
appropriate.
 AIDS vs. HIV+
• According to the Centers for Disease Control
(CDC), in order to diagnose a patient with
AIDS, documentation must clearly state:
– Patient diagnosed with AIDS defining
medical conditions
• Only confirmed cases of AIDS or HIV infection
should be reported (coded)
– Most AIDS cases in the U.S. are AIDS/HIV-1
– HIV-2 uncommon in the U.S.; mostly other
countries
 AIDS vs. HIV+ (cont.)
• Asymptomatic HIV/HIV+ are not the same as
AIDS/HIV infection
– Never report them together
• Asymptomatic HIV/HIV+ and inconclusive HIV
not the same
– Never report together with confirmed
diagnosis of AIDS/HIV infection
• When documentation states HIV-2:
– PDx=HIV-1
– SDx=HIV-2
 Inconclusive HIV
Inconclusive HIV Test
• Newborn babies born to HIV+ moms have
mom’s diagnosis due to antibody status
• HIV+ status in newborns lasts up to 18 months
– Sometimes newborn never become infected
– Known as a “False Positive”
– Inconclusive HIV test results another term for
“False Positive”
– Assign inconclusive test code when
documentation does not definitely state AIDS or
HIV+
 Stages of HIV Infection
• According to the National Institute of Health, the 3
stages of HIV infection are:
– Acute HIV – Chronic HIV Infection
– Exposed to HIV – Symptomatic HIV/HIV+
– Approximately 3 weeks to 8 – Approximately 1-3 years
months
– Chronic HIV ►AIDS
– Chronic HIV Infection – Advanced stages of HIV
– Asymptomatic HIV/HIV+ infection
– Approximately 5-10 years – Opportunistic infections
develop

• Various data suggests that there are 4 stages

• People living with HIV/AIDS face serious health threats
known as “opportunistic infections” (OI’s)
 Opportunistic Infections
• People with healthy immune systems can be exposed
to four (4) types of infections with no reaction:
− Viral infections − Fungal infections
• Kaposi Sarcoma • Candida
• Herpes • Cryptococcus
• Influenza (flu)
− Parasitic infections
− Bacterial infections
• Pneumocystis carinii
• Tuberculosis (TB)
• Strep pneumonia

– People living with HIV/AIDS are not as fortunate

 Opportunistic Infections (cont)
• HIV/AIDS related “OI’s” take advantage of the
weakened immune system resulting in life
threatening illnesses

• The most severe OI’s occur when the CD4 T-cell

count is below 200 cells/mm3

• OI’s are common in people with HIV/AIDS

– The most common cause of death

• Patients diagnosed with any OI’s are no longer
considered HIV+
 Commonly Used Codes
– The CDC has a comprehensive list of OI’s
located on their web page

Most common OI’s:

• Candidiasis (Thrush) • Toxoplasmosis (Toxo)
• Cytomegalovirus (CMV) • Tuberculosis (TB)
• Herpes simplex viruses • Recurrent severe bacterial
(chronic) pneumonia
• Kaposi Sarcoma • Wasting Syndrome
• Mycobacterium avium • Malaria
complex (MAC or MAI)
• Pneumocystis pneumonia
(PCP)
 Commonly Used Codes (2)
ICD-9-CM ICD-10-CM
Codes Description Codes Description
HIV Disease HIV Disease
−AIDS −AIDS

042 −AIDS Like Syndrome

−AIDS Related Complex (ARC) B20 −AIDS Like Syndrome
−AIDS Related Complex (ARC)
−Symptomatic HIV Infection −Symptomatic HIV Infection
−HIV 1 −HIV 1

– Asymptomatic human – Asymptomatic human

immunodeficiency virus immunodeficiency virus [HIV]
[HIV] infection status
V08 – Asymptomatic HIV status Z21 –
infection status
Asymptomatic HIV status
−HIV+ −HIV+
−HIV + status −HIV + status
 Commonly Used Codes (3)
ICD-9-CM ICD-10-CM
Codes Description Codes Description

Nonspecific Inconclusive laboratory evidence

Evidence of HIV of human immunodeficiency virus
795.71 −Inconclusive R75 [HIV]
HIV Test (Adult) – Non-conclusive HIV test
(Infant)
findings in infants
– Human immune – Human immunodeficiency virus
deficiency virus
V65.44 [HIV] counseling Z71.7 [HIV] counseling
– HIV Counseling – HIV Counseling

Encounter for screening for human

Special Screening Z11.4 immunodeficiency virus [HIV]
for Other Specified
V73.89 Viral Diseases
Encounter for screening for other
(HIV/AIDS) Z11.59 viral diseases
 Commonly Used Codes (4)
ICD-9-CM ICD-10-CM
Codes
Description Codes
Description
Contact With/Exposure to – Contact with and (suspected)
Other Viral Diseases (HIV/AIDS) exposure to human
V01.79 −PrEP Z20.6 immunodeficiency virus [HIV]
NOTE: Code also maps to
Z20.5, Z20.828 – PrEP

Z72.51 High risk heterosexual behavior

V69.2 High Risk Sexual Behavior Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Other Problems Related to
Lifestyle
−Asymptomatic high risk
Other problems related to
V69.8 −Report as SDx code only Z72.89 lifestyle
(when applicable)
NOTE: Code also maps to
Z72.0, Z72.821, Z73.0-Z73.3)
 Commonly Used Codes (5)
ICD-9-CM ICD-10-CM
Codes Description Codes Description

−Human T-cell Human T-cell lymphotropic virus,

079.52 lymphotropic virus, B97.34 type II [HTLV-II] as the cause of
type II [HTLV-II] diseases classified elsewhere

HIV 2 Human immunodeficiency virus,

−Report as SDx code
079.53 only (when
B97.35 type 2 [HIV 2] as the cause of
applicable)
diseases classified elsewhere

Other specified Encounter for other procedures

V07.8 prophylactic Z41.8 for purposes other than
measure remedying health state
Screening Encounter for screening for
V74.5 examination for Z11.3 infectious with a predominantly
venereal disease sexual mode of transmission
 Commonly Used Codes (6)
ICD-9-CM ICD-10-CM
Codes Description Codes Description
– Other long term (current) drug
therapy
– Long term (current) drug
Long-term (current) use
V58.69 of other medications
Z79.899 therapy
– Includes long term (current)
drug use for prophylactic
purposes

Encounter for screening for

Screening examination
V74.5 for venereal disease
Z11.3 infectious with a predominantly
sexual mode of transmission

Code Instructional Notes State:

– Code also any therapeutic drug level monitoring (Z51.81)
– EXCLUDES2
– Drug abuse and dependence (F11-F19)
– Drug use complicating pregnancy, childbirth and the puerperium
(O99.32-)
 Commonly Used Codes (7)
Opportunistic Infections:
ICD-9-CM ICD-10-CM
Codes Code Description Codes
112.0-112.9 Candidiasis (Thrush) B37.0-B37.9
078.5 Cytomegalovirus (CMV) B25.0-B25.9
Herpes Simplex Virus (chronic)
054.10-054.19 A60.00-A60.9
(HSV)
176.0-176.9 Kaposi Sarcoma C46.0-C46.9
084.0-084.9 Malaria B50.0-B50.9

NOTE: Check CDC’s website for comprehensive list of OI’s

 Commonly Used Codes (8)
ICD-9-CM Codes Code Description ICD-10-CM Codes

Mycobacterium Avium Complex

031.2 (MAC or MAI) A31.2
Pneumocystis Carinii Pneumonia
136.3 (PCP) B59
130.0-130.9 Toxoplasmosis (Toxo) B58.00-B58.9
011.00-018.96 Tuberculosis (TB) A15.0-A19.9
Recurrent severe bacterial
482.9 pneumonia J15.9
Cachexia
799.4 R64
•
• Wasting syndrome

NOTE: Check CDC’s website for comprehensive list of OI’s

 Other Codes
Accidental Finger Stick
ICD-9-CM ICD-10-CM
Code Description Codes Description
Contact with hypodermic needle, initial
W46.0xxA encounter
Contact with hypodermic needle,
W46.0xxD subsequent encounter
– Accident
caused by W46.0xxS Contact with hypodermic needle, sequela
E920.5 hypodermic Contact with contaminated hypodermic
needle W46.1xxA needle, initial encounter
– Needlestick
Contact with contaminated hypodermic
W46.1xxD needle, subsequent encounter
Contact with contaminated hypodermic
W46.1xxS needle, sequela

Never sequenced as the principal diagnosis code

 New Coding Changes
• Some codes now require the following 7th
character values:
– Disease of the musculoskeletal system
(pathological fractures)
– Injury, Poisoning and Certain Other
Consequences of External Causes
7th Digit Description Coding Guidelines
Patient receiving active treatment i.e.
A Initial encounter surgery, ED, Physician clinic/Office visit
Patient completes active treatment and
D Subsequent encounter presents for routine follow
Patient follow up for sequela or residual
S Sequela effect
 Other Codes (2)
ICD-9-CM ICD-10-CM
Code
Description Codes Description

O98.41- Viral hepatitis complicating pregnancy

Other Other viral diseases complicating
maternal viral O98.51- pregnancy
disease
Human immunodeficiency virus [HIV]
647.6x
complicating
pregnancy,
O98.71- disease complicating pregnancy
childbirth, or Human immunodeficiency virus [HIV]
the O98.72 disease complicating childbirth
puerperium
Human immunodeficiency virus [HIV]
O98.73 disease complicating the puerperium
 Other Codes (3)
5th Digit classification for 6th Digit classification for
ICD-9-CM ICD-10-CM
0 - unspecified episode of care 0 - unspecified episode of care
1 - deliveried 1 - first trimester
2 - delivered with post partum 2 - second trimester
complications 3 - third trimester
3 - antepartum 9 - unspecified trimester
4 - postpartum
condition/complications
 Other Codes (4)
ICD-9-CM ICD-10-CM
Codes
Description Codes Description
Supervision of Encounter for supervision of normal
V22.0 normal 1st Z34.00 first pregnancy, unspecified
pregnancy trimester
Encounter for supervision of other
Z34.80 normal pregnancy, unspecified
Supervision of trimester
V22.1 other pregnancy Encounter for supervision of normal
Z34.90 pregnancy, unspecified,
unspecified trimester
Pregnancy state,
V22.2 incidental Z33.1 Pregnancy state, incidental
Documentation and Coding Tips
Complications of Pregnancy, Childbirth and the
Puerperium
– Significant terminology changes
– ICD-9 codes denote antepartum vs postpartum complications
– ICD-10 codes denotes trimester
– All medical records must clearly reflect the number of weeks
completed (or trimester) for the current admission or
encounter:
– First trimester: less than 14 weeks
– Second trimester: 14 weeks to 28 weeks
– Third trimester: 28 weeks until delivery date
– Codes from this section take precedence over codes from
other sections
– Some codes require 7th character designation that denotes
the number of newborns (fetuses)
 Other Codes (5)
Well Visits
ICD-9-CM ICD-10-CM
Codes Description Codes Description
Encounter for general adult medical
– Routine General Z00.00 examination without abnormal
V70.0 Medical Exam findings
– Well Visit Encounter for general adult medical
*Z00.01 examination with abnormal findings
Encounter for routine child health
*Z00.121 examination with abnormal findings
Routine infant or
V20.2 child health check Encounter for routine child health
Z00.129 examination without abnormal
findings

NOTE: *Use additional code to identify any abnormal findings

 Other Codes (6)
ICD-9-CM ICD-10-CM
Codes Description Codes Description
– Health supervision for – Health examination for
newborn under 8 days newborn under 8 days old
V20.31 old *Z00.110 – Health check for newborn
– Health check for newborn
under 8 days old under 8 days old

– Health supervision for – Health examination for

newborn 8 to 28 days old newborn 8 to 28 days old
V20.32 – Health check for newborn *Z00.111 – Health check for newborn 8
8 to 28 days old to 28 days old
– Newborn weight check – Newborn weight check

NOTE: *Use additional code to identify any abnormal findings

 New Coding Changes
Well Visit Code Tips
– ICD-10-CM Codes: Z00.01, Z00.121
– Abnormal findings during well visit encounters that are revealed
in diagnostic test findings should be coded as “with abnormal
findings”
– Codes that indicate “with abnormal findings” require reporting
an additional code that describes the abnormal findings
– ICD-10-CM Codes: Z00.00, Z00.129
– Complaints that are evaluated during the well visit encounters
should be coded as “without abnormal findings”
– Code selection based upon the information known at the time
of the encounter
– If findings or test results are not available at the time of the
medical encounter, report codes that indicate “without
abnormal findings”
 Other Codes (7)
ICD-9-CM ICD-10-CM
Codes
Description Codes Description
Z70.0 Counseling related to sexual attitude

Counseling related to patient’s

V65.49
Other specified Z70.1 sexual behavior and orientation
counseling
Counseling related to sexual
Z70.3 behavior and orientation of third
party (child, partner, spouse)
Encounter for follow-up examination
Z08 after completed treatment for
malignant neoplasm
Unspecified
V67.9 follow up exam Encounter for follow-up examination
after completed treatment for
Z09 conditions other than malignant
neoplasm
 Diagnoses Coding Tips
Never report the code for AIDS (B20) or HIV+
(Z21) when the record states:
• Suspected • Questionable
• Suspicion of • Consistent with
• Possible • Presumed to be
• Likely • Appears
• Rule out
Instead, report the codes for the:
• Presenting complaint
• Chief complaint
• Signs or symptoms
– Example: muscle aches, rash, mouth/genital ulcers,
swollen lymph glands (neck), fever
Query physician for clarification
Diagnoses Coding Tips (cont)
“Active” versus “History of”
Active translates to “the current the condition”
• B20 - AIDS/HIV Infection • Z21 - HIV+

– Codes for “History of” AIDS does not exist

– Report AIDS (Dx code B20)
– Codes for “History of” HIV infection/ HIV+ does not
exist
– Report AIDS (Dx code Z21)

Provider documentation must clearly denote the medical

condition to ensure proper coding in the outpatient settings
Maximizing Third Party Reimbursement
Through Enhanced
Medical Documentation and Coding

Coding Scenarios
 HIV Pre-Testing with Preventive Care
Case study #1: A 27 year old patient presents to her
primary care physician’s office concerned about
recently having unprotected sex and requests an HIV
test. The physician notices that the patient is also due
for a well visit this year and performs it. Dr. Attending
decides to perform a preventive medicine visit exam,
spends 35 minutes counseling the patient and performs
a rapid HIV test. This is an established patient.

ICD-9-CM ICD-10-CM
General Medial Exam (Well Visit) V70.0 Z00.00
Special Screening for other specified
viral diseases (HIV screening) V73.89 Z11.4
HIV Counseling V65.44 Z71.7
High Risk Sexual Behavior V69.2 Z72.51
HIV Pre-Testing with Preventive Care (2)
Case Study #1 Rationale
– This is a general medical exam (well visit) for a
patient that presents with no medical
problems
– The codes should be sequenced as follows:
 PDx=well adult exam code (Z00.00)
 SDx=HIV (special) screening test code (Z11.4)
 3rd =HIV counseling code (Z71.7)
 4th =unprotected sex code (Z72.51)
 HIV Post-Test Counseling Negative Results

Case study #2: The patient (from case study#1) returns for
their HIV test results. The physician advises the patient that
the results are negative and counsels the patient for 30
minutes on the importance of safe sex and contraceptive
methods. The physician also distributes contraception and
advises the patient to return in 3 months for a retest.

ICD-9-CM ICD-10-CM
HIV Counseling V65.44 Z71.7
High Risk Sexual
Behavior
V69.2 Z72.51
HIV Post-Test Counseling Negative Results (2)

Case Study #2 Rationale

– Patient returned for HIV test results
– Physician documents the results and
counsels patient on the importance of
safe sex practices
 PDx=Counseling code (Z71.7)
 SDx=High risk sexual behavior code
(Z72.51)
 HIV Post-Test Counseling Positive Results
(Asymptomatic)
Case study #3: The patient returns for their HIV test
results. The physician advises the patient that they are
HIV+ (asymptomatic HIV). The physician counsels the
patient and explains what it means to have a
diagnosis of HIV+ vs. HIV infection, the proper use of
medications, implements a treatment plan and
advises the patient to return in 3 months for a retest.
This is an established patient visit.
ICD-9-CM ICD-10-CM
Asymptomatic HIV (HIV+, HIV+
status) V08 Z21
HIV Counseling V65.44 Z71.7
 HIV Post-Test Counseling Positive Results
(Asymptomatic) (cont.)

Case Study #3 Rationale

– Patient returned for HIV test results
– Medical record states patient is HIV+
– Physician counsels patient, gives patient some
literature that explains what HIV+ is, the
difference between HIV+ vs AIDS and also
discusses the importance of safe sex practices
 PDx=HIV+ condition code (Z21)
 SDx=counseling code (Z71.7)
 HIV Post-Test Counseling Positive Results
(Symptomatic)
Case study #4: The patient returns for their HIV test results.
The physician advises the patient that they have the HIV
infection (symptomatic HIV/AIDS). The physician counsels
the patient and explains in detail what HIV infection is.
The physician implements a treatment plan, discusses the
importance of taking medications and the importance of
practicing safe sex at all times. This is an established
patient visit.

ICD-9-CM ICD-10-CM
AIDS (HIV infection) 042 B20
HIV Counseling V65.44 Z71.7
 HIV Post-Test Counseling Positive Results
(Symptomatic) (2)

Case Study #4 Rationale

– Patient returned for HIV test results
– Medical record states patient has AIDS
– Physician counsels patient and explains in
detail what HIV infection is, initiates
treatment plan, discusses the importance
of taking medications and the importance
of practicing safe sex at all times
 PDx=AIDS condition (B20)
 SDx=counseling code (Z71.7)
 HIV Post-Test Counseling Positive Results
(Symptomatic) (3)

Case study #5: The patient returns for their HIV test
results. The physician advises the patient that they
advanced HIV (HIV-2). The physician counsels the patient
and explains in detail what HIV infection is. The physician
implements a treatment plan, discusses the importance of
taking medications and the importance of practicing safe
sex at all times. This is an established patient visit.
ICD-9-CM ICD-10-CM
AIDS (HIV infection) 042 B20
HIV-2 Infection 079.53 B97.35
HIV Counseling V65.44 Z71.7
 HIV Post-Test Counseling Positive Results
(Symptomatic) (4)

Case Study #5 Rationale

– The patient returned for HIV test results
– The medical record states that the patient has
advanced HIV so physician counsels patient and
explains in detail what HIV infection is
– Physician initiates treatment plan, discusses the
importance of taking medications and the importance
of practicing safe sex at all times
 PDx=AIDS condition (B20)
 SDx=HIV-2 condition (B97.35)
 3rd=Counseling coding (Z71.7)
 HIV Counseling without Testing
Case study #6: A 17 year old patient presents to her GYN
to discuss contraception options and safe sex. Dr.
Attending counsels the patient on the various methods
and suggests and HIV test. The patient agrees, but then
minutes later declined to the HIV screening test. Dr.
Attending spends 45 minutes counseling the patient and
asked her to reconsider the HIV test at a later date.

ICD-9-CM ICD-10-CM
HIV Counseling V65.44 Z71.7
Case Study#6 Rationale
– The patient presents for counseling on the various
contraception options and safe sex
– PDx=HIV counseling code (Z71.7)
 Antiretroviral Therapy Visit Newborn
Case study #7: An HIV+ mom presents to the
pediatrician’s office for antiretroviral therapy follow for her
2 month old baby. The physician documents an
expanded problem focused history and performs a brief
exam. Upon review of the lab results, the physician makes
the decision to modify the antiretroviral medication. A
revised treatment plan is discussed and the physician
advises the patient to return in 1 month.
ICD-9-CM ICD-10-CM
Inconclusive HIV Test 795.71 R75
Pre-exposure
prophylaxis
V01.79 Z20.6
Antiretroviral Therapy Visit Newborn (2)

Case Study #7 Rationale

– HIV+ mom takes 2 month old to pediatrician’s
office for antiretroviral therapy follow up
– Baby does not have a confirmed HIV+ or HIV
condition
– HIV+ diagnosis is mom’s antibody status
 “False positive” diagnosis could last up to
18 months in newborns
 PDx=Inconclusive HIV results code (R75)
 SDx=PrEP code (Z20.6)
 Office Visit AIDS Related
Case study #8: Patient with a history of AIDS
comes to his primary care doctor for complaints
of fever and extreme fatigue due to possible
pneumonia. The final diagnoses are Pneumocystis
carinii pneumonia (PCP) and AIDS.

ICD-9-CM ICD-10-CM
AIDS 042 B20
PCP 136.3 B59
Office Visit AIDS Related (2)
Case Study #8 Rationale
– Patient with AIDS presents with complaints
of fever and extreme fatigue
– Final diagnoses documented in the
medical record are Pneumocystis carini
pneumonia (PCP) due to AIDS
– Minimum of 2 diagnoses codes necessary to
accurately code this scenario
– Coding guidelines state when AIDS related
conditions (OI) are present sequence AIDS as
PDx
 PDx - AIDS: B20
 SDx – PCP (AIDS related OI): B59
66
 Office Visit non-AIDS Related
Case study #9: Patient with a history of AIDS and post op TAH presents
with complaints of nausea, vomiting and dehydrated due to chemo
treatment earlier today. The patient also needed a refill of AIDS
meds. The physician documents a detailed history with moderate
medical decision making. The final diagnoses are nausea, vomiting,
dehydration due to chemo, invasive endo-cervical cancer and AIDS.

ICD-9-CM ICD-10-CM
Nausea with vomiting due to chemo 787.01 R11.2
Dehydration due to chemo 276.51 E86.0
Invasive endo-cervical cancer 180.0 C53.0
Adverse effects of antineoplastic drugs E933.1 T45.1x5A
AIDS 042 B20
Office Visit non-AIDS Related (2)
Case Study #9 Rationale
– Patient with h/o AIDS presents with complaints of
nausea, vomiting and dehydration due to chemo
treatment
– Reason for medical care is not related to AIDS so
this diagnosis should not be sequenced as the
primary diagnosis
 PDx: nausea with vomiting due to chemo treatment
=R11.2
 SDx: dehydration due to chemo treatment=E86.0
 3rd: cervical cancer=C53.0
 4th: adverse effects of chemo treatment =T45.1x5A
 5th: AIDS condition=B20
 Office Visit non-AIDS Related (3)
Case study #10: A 5 month (20 weeks) pregnant
patient with a history of AIDS presents to her OB
appointment complaining of severe cramping
and heavy bleeding. She was put on IV meds
and the bleeding stopped The patient was sent
to Labor and Delivery.

ICD-9-CM ICD-10-CM
Threatened abortion in early
pregnancy 640.00 O20.0
Infectious and parasitic conditions
complicating pregnancy 647.60 O98.712
AIDS 042 B20
 Office Visit non-AIDS Related (4)
Case Study #10 Rationale
– Pregnant patient presents for prenatal
appointment complaining of severe cramping and
heavy bleeding
– Code sequencing guidelines for pregnant patients
state that the pregnancy codes are always
sequenced as the principal diagnosis even when
the patient is diagnosed with AIDS
 PDx=pregnancy complication code (O20.0)
 Sx=infectious and parasitic conditions in pregnancy
(O98.71)
 3rd code=AIDS code (B20)
NOTE: If a pregnant patient with asymptomatic HIV infection status is
admitted during pregnancy, childbirth or the puerperium, assign
codes O98.71and code Z21 for asymptomatic HIV infection
 PEP Visit Office Staff
Case study #11: A medical assistant accidentally punctures finger with
needle after drawing bloods from an AIDS patient. The office manager
completes the workplace injury forms while the medical assistant is treated by
physician in your office. The physician performs a detailed history and
problem focused exam. Medical decision making includes blood work, a
supply 48 hour PEP medication and counsels the medical assistant regarding
transmission prevention. Bloodwork sent to lab for processing.

ICD-9-CM ICD-10-CM
Special Screening for Other Specified Viral
Diseases (HIV/AIDS) V73.89 Z11.4
Pre-exposure prophylaxis V01.79 Z20.6
HIV counseling V65.44 Z71.7
Contact with contaminated hypodermic
needle, initial encounter (ICD-9 says accident) E920.5 W46.1xxA
 PEP Visit Office Staff (2)
Case Study #11 Rationale:
– This is an encounter for an accidental needle stick
after drawing bloodwork from an AIDS patient
– The codes should be sequenced as follows:
 PDx=HIV (special) screening test code (Z11.4)
 SDx=Contact with or (suspected) exposure to HIV (Z20.6)
 3rd =HIV counseling code (Z71.7)
 4th=contact with contaminated hypodermic needle
(W46.1xxA)
– This is an external cause code that further describes the
accidental finger stick
 Risk Based Revenue
• Physicians’ income historically driven by
procedural coding and documentation; not
diagnoses
– Physician undercoding and overcoding a major
threat to revenue
– Reimbursement adversely affected, if physicians do
not document the full range of diagnoses and
complications treated
– Significant co-morbidities and severity greatly
influence reimbursement
• Diagnosis of AIDS/HIV+ map to chronic condition
risk pools
 Risk-Based Revenue (2)
– All patients are assigned a severity level (risk
score) based on chronic health conditions
– Projects health care utilization and costs
– Patient demographics, procedures/services,
pharmacy claims and medical claims contain
diagnoses
 Diagnoses Coding Tips
• Assign all diagnoses code that accurately
describes the medical problem being treated
or the reason for health care encounter (Dx
code ranges: A00.0-T88.9xxA; AIDS/HIV: B20,
Z21)
– Significant chronic conditions documented in
medical record should be coded accordingly
– Greatly impacts risk based reimbursement and
quality incentives (QARR/HEDIS, PQRS)
– Codes reported on health care claims should match
information documented in the health record
 Diagnoses Coding Tips (2)
Code Sequencing
• When it is necessary to report multiple
diagnoses codes, accurate interpretation of
coding guidelines ensures proper code
sequencing
– Ensure proper sequencing of all diagnoses codes;
especially for procedures & diagnostic tests
– Coding guidelines that denote “principle
diagnosis” vs. “secondary diagnosis” only, must
be adhered to
 Diagnoses Coding Tips (3)
− Codes designated as principal diagnosis
codes are always sequenced first
− Codes designated as
secondary/subsequent diagnoses codes
are never sequenced first
− OI codes are always assigned as the
secondary diagnoses if supported by medical
record documentation
•ICD-10-CM code B20 always the principal diagnosis
•OI condition code always the secondary diagnosis
 Documentation Tips
Still Using Paper Charts?
• Use standard medical abbreviations, acronyms,
or symbols
• Do not use arrows up/down (↑↓) in place of
“hyper-“ and “hypo-“, as they could be
misinterpreted
• Medical conditions under physician care must
clear and concise to ensure proper translation
to numeric diagnoses codes
 Documentation Tips (2)
• Each visit date documented in the
medical record must be able to “stand
alone”
– Chronic conditions documented in one note,
must be re-documented in every subsequent
note when treatment is directed to the
condition
– Documentation which states, see previous
visit, prior note, problem list, etc., are
deemed unacceptable
 Documentation Tips (3)
• Problem lists with no evaluation or
assessment of medical conditions in chart
deemed unacceptable for encounter
data submission
– CMS mandates that an evaluation of each medical
condition be documented in the medical record;
not just the condition listed as “a problem”
– HIV+ - stable on meds
– DM w/Neuropathy - meds adjusted
– CHF – compensated
– COPD – test ordered
– HTN – uncontrolled
– Hyperlipidemia - stable on meds
 Why Is Documentation Important?

• Medical record documentation must support

the services submitted on claims to the local
Medicaid agency
– Codes reported on health care claims should
match
• Documentation should substantiate:
− Medical necessity (diagnoses being treated)
− Final diagnosis code selection
Why Is Documentation Important? (2)

• Documentation inaccuracies result in payment

recovery and heavy sanctions by the Office of
Medicaid Inspector General (OMIG)
− Sanctions and penalties include:
• Restricted/Excluded from provider
participation
• Termination from provider participation
• Huge fines
• Jail time
SERIES 3 – POLLING QUESTION#5
Case Study: Patient returns for HIV test results and also
HTN prescriptions refills. The physician advises the
patient of their results; confirmed AIDS condition. The
physician spends 15 minutes counseling the patient
on the importance of safe sex, distributes HIV/AIDS
education literature and implements a treatment
plan. After rechecking the blood pressure and noting
142/90 as unusually high. Medication dosage is
increased, prescriptions and referral to see a
nutritionist given to patient. This is an expanded
problem focused history with moderate medical
decision making for an established patient visit.
 Closing Comments
• Medical record documentation must support
the services submitted on claims to the local
Medicaid agency
– Codes reported on health care claims should
match
• Documentation should substantiate:
− Medical necessity (diagnoses being treated)
− Final diagnosis code selection
 Closing Comments (cont)
• Documentation inaccuracies result in payment
recovery and heavy sanctions by the Office of
Medicaid Inspector General (OMIG)
− Sanctions and penalties include:
• Restricted/Excluded from provider
participation
• Termination from provider participation
• Huge fines
• Jail time
 Web Resources
Centers for Medicare and Medicaid Services (CMS)
http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html
http://www.cms.gov/center/coverage.asp

Food and Drug Administration (FDA) [Link]

American Medical Association (AMA) [Link]

National Center for Health Statistics (NCHS) [Link]

Centers for Disease Control (CDC)

http://www.cdc.gov/hiv/
 Web Resources (cont.)
• American Academy of Professional Coders (AAPC)
http://www.aapc.com/resources/index.aspx

• American Health Information Management Association (AHIMA)

http://www.ahima.org/resources/default.aspx

• The American Academy of Family Physicians (AAFP)

http://www.aafp.org/online/en/home/practicemgt/codingresources.html

• American Hospital Association (AHA)

http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml
 Other Resources
• ICD-9-CM, Volumes 1 & 2, Professional. Publisher:
Ingenix Optum.
• ICD-10-CM, Volumes 1 & 2, Professional. Publisher:
Ingenix Optum.
• Faye Brown’s ICD-10-CM Coding Handbook 2015 (with
Answers). Publisher: American Hospital Association.
• ICD-10-CM Fast Finder Sheets. Publisher: Ingenix Optum.
Note: Coding resources are updated annually. Please be sure to update coding
resources each year.
 Contact
HealthHIV
2000 S ST NW
Washington, DC 20009
202.507.4730
www.HealthHIV.org

Brian Hujdich
[email protected]

Michael D. Shankle, MPH

[email protected]