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Coding Guidelines and Instructional Notes for ICD-10-CM Chapter 1 Exam/Q/A
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Coding Guidelines and Instructional Notes for ICD-10-CM Chapter 1 Exam/Q/A
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Coding Guidelines and InstructionalNotes for ICD-10-CM Chapter 1 Exam/Q/A
Guideline I.C.1.a. Human Immunodeficiency Virus [HIV] Infections
1.Code only confirmed cases - -The provider's diagnostic statement that the
patient is HIV positive, or has an HIV-related illness is sufficient.
-Guideline I.C.1.a. Human Immunodeficiency Virus [HIV] Infections
2.Selection and sequencing of HIV codes - -
-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, Human
immunodeficiency virus [HIV] disease followed by additional diagnosis codes
for all reported HIV-related conditions.
-2.Selection and sequencing of HIV codes
b. Patient with HIV disease admitted for unrelated condition - -b. Patient with
HIV disease admitted for unrelated condition injury code) should be the
principal diagnosis. Other diagnoses would be B20 followed by additional
diagnosis codes for all reported HIV-related conditions.
-2.Selection and sequencing of HIV codes
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.
-2.Selection and sequencing of HIV codes
d. Asymptomatic human immunodeficiency virus - -Z21, Asymptomatic
human immunodeficiency virus [HIV] infection status, 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.
-2.Selection and sequencing of HIV codes
e. Patients with inconclusive HIV serology - -Patients with inconclusive HIV
serology, but no definitive diagnosis or manifestations of the illness, may be
assigned code R75, Inconclusive laboratory evidence of human
immunodeficiency virus [HIV].
-2.Selection and sequencing of HIV codes
, 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 HIV illness (B20) should never be assigned to R75 or
Z21, Asymptomatic human immunodeficiency virus [HIV] infection status.
-g.HIV Infection in Pregnancy, Childbirth and the Puerperium - -During
pregnancy, childbirth or the puerperium, a patient admitted (or presenting
for a health care encounter) because of an HIV-related illness should receive
a principal diagnosis code of 098.7-, Human immunodeficiency [HIV] disease
complicating pregnancy, 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. Patients with asymptomatic HIV infection status
admitted (or presenting for a health care encounter) during pregnancy,
childbirth, or the puerperium should receive codes of 098.7- and Z21.
-h. Encounters for testing for HIV - -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. If a patient with signs or symptoms is being seen for HIV
testing, code the signs and symptoms. 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 result is negative, use code
Z71.7, Human immunodeficiency virus [HIV] counseling. If the results are
positive, see previous guidelines and assign codes as appropriate.
-Guideline I.C.1.b. Infectious Agents as the Cause of Diseases Classified to
Other Chapters - -Certain infections are classified in chapters other than
Chapter 1 and no organism is identified as part of the infection code. In these
instances, it is necessary to use an additional code from Chapter 1 to identify
the organism. A code from category B95, Streptococcus, Staphylococcus,
and Enterococcus as the cause of diseases classified to other chapters, B96,
Other bacterial agents as the cause of diseases classified to other chapters,
or B97, Viral agents as the cause of diseases classified to other chapters, is
to be used as an additional code to identify the organism. An instructional
note will be found at the infection code advising that an additional organism
code is required.
-Guideline I.C.1.c. Infections Resistant to Antibiotics - -Many bacterial
infections are resistant to current antibiotics. It is necessary to identify all
infections documented as antibiotic resistant. Assign a code from category
Z16, Resistance to antimicrobial drugs, following the infection code only if
the infection code does not identify drug resistance.
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