Definition:
HIV Disease is caused by human immunodeficiency virus, of all types, with destruction of CD4+ T-lymphocytes that help mediate the body’s immune response to infection.
· The virus is bloodborne
· It is most often transmitted through:
o Sexual intercourse
o Shared IV drug needles
o Mother-to-child transmission during birth or breastfeeding
Diagnostic Criteria:
The CDC is responsible for establishing the definitive case definitions of HIV infection and HIV disease (AIDS).
- HIV infection (HIV + without AIDS)- Identified through two different HIV antibody or antigen/antibody tests or by non-antibody virologic testing. This describes a person with a + HIV test but does meet the criteria for HIV disease (AIDS).
· HIV disease/AIDS- An HIV + patient with a past or present occurrence of one of the following:
o Absolute CD4+ T-lymphocyte count< 200 or
o An AIDS defining condition
· CDC AIDS-defining conditions:
o Pneumocystis pneumonia
o Certain lymphomas
o Systemic candidiasis
o Kaposi’s sarcoma
o Other unusual bacterial, fungal, parasitic, viral infections
· The complete list of AIDS defining conditions can be found at www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a2.htm.
· The stages of HIV are defined by the CD4 count (cells /uL):
o Early (CD4 > 500)
o Intermediate (CD4 200-500)
o Advanced (CD4 100-200)
o Late stage (CD4 < 100)
Coding Considerations:
- HIV disease/AIDS (B20)- If B20 has ever been diagnosed and coded, then it will always be coded on subsequent encounters.
- HIV + (Z21)-Used when the patient has never been diagnosed with AIDS or AIDS-defining diagnosis.
- Only confirmed cases of HIV are coded, not suspected or probable.
- 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.
- Sequencing of HIV codes
- 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.
- Exceptions:
- Hemolytic-uremic syndrome associated with HIV disease
- HIV in pregnancy: If a patient is admitted because of an HIV-related illness, assign O98.7-, Human immunodeficiency [HIV] disease complicating childbirth and the puerperium, followed by B20 and the code(s) for the HIV-related illness(es). Codes from Chapter 15 always take sequencing priority.
- If a patient with a history of HIV disease is currently managed on antiretrovirals, assign code B20.
- Review the following Coding Clinics:
- AHA Coding Clinic, First Quarter 2022, p. 36
- AHA Coding Clinic, First Quarter 2022, p. 27
- AHA Coding Clinic, First Quarter 2021, p. 52
- AHA Coding Clinic, Fourth Quarter 2020, p. 97
- AHA Coding Clinic, Second Quarter 2020, p. 23
- AHA Coding Clinic, First Quarter 2019, p. 8
- Exceptions:
- 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.
CDI Practice Considerations:
- The CDC recommends using the term HIV disease to describe AIDS.
- The term HIV infection describes an HIV+ person who does not meet criteria for HIV disease.
- If the provider has documented HIV, HIV+, or HIV infection, but prior records show the code B20, a query may be necessary for clarification.
- B20 provides a CC as a secondary diagnosis and both B20 and Z21 will influence risk adjustment.
- When HIV is assigned as EITHER the PDx or as a SDx, with a “major related” condition, an HIV DRG will be assigned.
- HIV DRGs:
- HIV “major related” conditions: Pneumonia, Encephalopathy, Sepsis, Endocarditis, Lymphoma, Histoplasmosis, Oral thrush, Cryptococcus, Cytomegalovirus, Toxoplasmosis, Myelitis, Herpes viral infections, Organic mental disorders, Psychosis, Salmonella infections, etc.
- If a patient is admitted and treated for a condition that is not on the “major related” condition list, the PDx is the unrelated condition and HIV is secondary.
- Example: Pt with HIV disease falls and is admitted for hip fracture and ORIF, the PDx is hip fracture and B20 is a CC.
- CDI reviews should consider the CD4 count when reviewing for the presence of possible infections or complications.
- A provider must link or unlink the HIV to the admission diagnosis. When documentation is unclear, a query should be placed.
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