June 25, 2007
Coding for HIV and AIDS
For The Record
Human immunodeficiency virus (HIV), a virus causing acquired immunodeficiency syndrome (AIDS), is transmitted through contact with bodily fluids containing infected plasma or cells. HIV may be present in any bodily fluid, such as blood, semen, vaginal secretions, breast milk, and saliva. Of the five fluids listed, transmission by saliva has not been documented. If a patient has the virus, a blood test will be positive for HIV antibodies.
Being HIV positive is not the same as having AIDS. Many patients may test positive for HIV but don’t become sick for many years. If the patient is HIV positive but is also asymptomatic—does not have an HIV-related illness—and has not been diagnosed previously with an HIV-related illness, assign ICD-9-CM code V08, Asymptomatic human immunodeficiency virus infection status. “Do not use [code V08] 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 042 in these cases” (**AHA Coding Clinic for ICD-9-CM##, 2006, fourth quarter, page 153).
Patients with inconclusive or nonspecific HIV test results should receive code 795.71, Nonspecific serologic evidence of human immunodeficiency virus.
Only confirmed cases of AIDS or HIV infection should be coded. Do not assign a code for the HIV infection if it is documented as possible, suspected, etc. This is an exception to the coding guideline that states conditions may be coded in the inpatient setting if documented as possible, probable, or suspected.
AIDS is classified to code 042, Human immunodeficiency virus disease, which, according to ICD-9-CM guidelines, includes the following terms:
• Acquired immune deficiency syndrome;
• Acquired immunodeficiency syndrome;
• AIDS-like syndrome;
• AIDS-related complex; and
• HIV infection, symptomatic.
The physician does not have to specifically document AIDS in the medical record before code 042 can be assigned. “If the physician does not diagnose AIDS, the patient may still be classified as having AIDS if he or she is infected with HIV and has the condition listed as ‘with’ or ‘due to’ HIV infection in ICD-9-CM” (**AHA Coding Clinic for ICD-9-CM##, 1992, first quarter, pages 3-4). If the patient has an HIV-related illness, code 042 should be assigned (**AHA Coding Clinic for ICD-9-CM##, 2006, fourth quarter, pages 152-154). A determination does need to be made that the condition is related to the HIV. Some conditions, known as opportunistic infections, are inherent to HIV, such as pneumocystis carinii pneumonia (136.3) and Kaposi’s sarcoma (176.x). In these cases, code 042 is assigned and sequenced as the principal diagnosis. However, other conditions may or may not be HIV-related (eg, simple pneumonia, 486). If the documentation is unclear, clarification from the physician is necessary.
The physician does not need to state that the patient has AIDS, just that the condition in question is related to HIV. If the patient has a known prior diagnosis of an HIV-related illness, assign code 042 on every subsequent admission. “Patients previously diagnosed with any HIV illness (042) should never be assigned to 795.71 or V08” (**AHA Coding Clinic for ICD-9-CM##, 2006, fourth quarter, page 153).
Sequencing of Codes
At least two codes are needed for complete coding of patients with an HIV-related illness: code 042, plus codes for the associated conditions. Ordinarily, code 042 will be sequenced as the principal diagnosis when the patient is admitted for treatment of the HIV-related illness. For example, if a patient is admitted for treatment of AIDS-related dementia, sequence code 042 as the principal diagnosis, followed by code 294.1x. A patient with an HIV infection may be admitted for treatment of an entirely unrelated condition, in which case the unrelated condition is listed as the principal diagnosis with additional codes assigned for the HIV infection (042) and the associated conditions, if any. In such cases, code 042 indicates a comorbidity rather than the reason for the hospitalization.
Most cases in the United States are due to HIV 1. However, if it is documented that the AIDS is due to HIV 2, then code 079.53 will be assigned as a secondary diagnosis after code 042.
HIV Infection in Pregnancy
If a patient is admitted during pregnancy, childbirth, or the puerperium because of an HIV-related illness, code 647.6x should be sequenced as the principal diagnosis followed by code 042 and the HIV-related illness codes. If the pregnant patient is asymptomatic, then code V08 should be assigned instead of code 042 (**AHA Coding Clinic for ICD-9-CM##, 2006, fourth quarter, page 153).
HIV Infection in Newborns
Infants from birth to the age of 18 months who test positive for HIV but do not exhibit any HIV symptoms or conditions should be assigned to code 795.71. However, if the physician documents that the patient has a diagnosis of HIV infection, then code 042 will be assigned regardless of the patient’s age.
Coding and sequencing for HIV and AIDS are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also use specific **AHA Coding Clinic for ICD-9-CM## and American Medical Association **CPT Assistant## references to ensure complete and accurate coding.
— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.