To assign ICD-9-CM diagnosis codes appropriately for AIDS and HIV-related conditions, the coder must keep in mind several extremely important coding guidelines. First, the coding of AIDS involves an exception to coding guideline 1.8, which states: "If the diagnosis documented at the time of discharge is qualified as 'probable,' 'suspected,' 'likely,' 'questionable,' 'possible' or 'still to be ruled out,' code the condition as if it existed or was established." A diagnosis of AIDS must be confirmed and substantiated by a physician in the medical record before a final diagnosis code of AIDS, 042 [Human Immunodeficiency Virus [HIV] Disease], is assigned. Not only is this important from the standpoint of public health statistics and not labeling a patient with a condition that does not exist, but it is also vital in terms of ensuring that patients with the disease are able to access various medical assistance programs.
Second, once a patient has developed an HIV-related illness, code 042 should always be assigned for that patient's record on every subsequent admission. In a sense, this code assignment recognizes that a patient cannot move "backwards" from fully developed AIDS to Asymptomatic Human Immunodeficiency Virus [HIV] Infection [V08] or Nonspecific Serologic Evidence of Human Immunodeficiency Virus [HIV] [795.71].
Further, it's important to understand the appropriate circumstances for assigning codes V01.79, V08 and 795.71. If a patient was exposed to HIV and no further information is available, assign code V01.79, Contact with or exposure to other viral diseases. Inconclusive HIV serology with no definitive diagnosis or manifestations of the HIV illness is assigned to code 795.71. If a patient presents to a health care facility for HIV testing and is asymptomatic, code V73.89, Screening for other specified viral disease, should be assigned, along with a secondary code of V69.2, High-risk sexual behavior, if this information is documented for the patient.
A patient may have signs or symptoms, or a confirmed HIV-related diagnosis, but is presenting to a facility for an initial test for HIV. For this initial encounter, code the signs and symptoms or the diagnosis without the 042 code for AIDS until the results are back confirming AIDS.
On the next encounter, when the patient returns to be informed of the findings of the HIV test, assign code V65.44, HIV counseling, if the results are negative. If the results are positive but the patient is asymptomatic, assign code V08, Asymptomatic Human Immunodeficiency Virus [HIV] Infection. And of course, if the findings are positive and the patient is symptomatic, assign code 042, HIV Infection, with additional codes for the HIV-related conditions or symptoms. Ensure that code V02.9 [Carrier or suspected carrier of infectious disease, other specified infectious organism] is not assigned if the patient is HIV positive. Unlike other contagious diseases in which the patient can transmit the disease but may be asymptomatic, once the patient has tested positive for HIV, he/she is infected and can also transmit the disease.
Sequencing Is Important
Another very important component of appropriate coding for AIDS/HIV-related conditions involves sequencing. Generally, coders should follow guideline #2 for selection of principal diagnosis: the circumstances of the admission govern the selection of the principal diagnosis, "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."
When a patient is admitted for an HIV-related condition, a minimum of two codes should be assigned. First assign code 042 to identify the HIV disease, and then sequence additional codes to identify the other diagnoses. So if the patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV-related conditions.
How can a coder determine whether a condition is related to HIV? Ideally, the physician will document the cause-and-effect relationship between the two conditions. But there are several other opportunistic infectious disease processes that are always assumed to be related to HIV disease when present. These conditions include the following:
· Kaposi's sarcoma and lymphoma
· Pneumocystis carinii pneumonia (PCP)
· Cryptococcal meningitis
· Cytomegaloviral disease
Coders may also review a DRG reference and review the diagnosis codes in MDC 25, Human Immunodeficiency Virus Infections. ICD-9-CM diagnosis codes are designated as either significant HIV-related conditions or HIV major related conditions. When the above-mentioned conditions are present and are the reason for the admission, sequence code 042 as the principal diagnosis and then sequence the code for the underlying condition as a secondary diagnosis. If there is a question concerning whether a condition is related to known HIV infection, the physician should be queried.
If a patient with HIV disease is admitted for an unrelated condition, the code for the unrelated condition should be sequenced as the principal diagnosis. Other diagnoses should include code 042 followed by additional codes for all reported HIV-related conditions. Whether the patient is newly diagnosed or has had multiple previous admissions for HIV conditions is irrelevant to the sequencing decisions.
The other circumstance for which coders must assign appropriate HIV-related codes involves pregnant patients. If a patient is admitted because of an HIV-related illness during pregnancy, childbirth or the puerperium, assign code 647.6X [Other viral diseases in the mother classifiable elsewhere, but complicating the pregnancy, childbirth or the puerperium]. This should be followed by code 042 and code(s) for any HIV-related conditions. This guideline is an exception to the sequencing rule involving code 042 as listed above.
If a pregnant patient with asymptomatic HIV infection status is admitted during pregnancy, childbirth or the puerperium, assign codes 647.6X and code V08 for asymptomatic HIV infection.
To fully understand all coding guidelines related to AIDS and HIV-related conditions, the coder should carefully review the following Coding Clinic for ICD-9-CM issues:
4th Quarter 2007, p. 61; 3rd Quarter 2006, p. 14; 2nd Quarter 2004, p. 11; 1st Quarter 2004, p. 5; 1st Quarter 2003, p. 15; 2nd Quarter 1999, p.. 8; 1st Quarter 1999, p. 14; 4th Quarter 1997, pp. 30-31; 4th Quarter 1997, p. 60; 4th Quarter 1996, pp. 74-75; 4th Quarter 1994, pp. 29-36.
After reviewing the Coding Clinic references, test your knowledge with the quiz below.
1. A patient is admitted with a diagnosis of dementia related to advanced HIV disease. What is the correct code assignment?
a. 294.8, 042
b. 294.8, V08
c. 294.10, 042
d. 042, 294.10
2. A patient with AIDS was treated at this facility during the previous year for AIDS-related histoplasmosis. She is now admitted for acute nephritis, but there is no clear documentation in the record that the nephritis is due to the AIDS. What code should be sequenced as the principal diagnosis?
3. An asymptomatic HIV-positive patient was admitted for Interleukin immunotherapy. What is the appropriate principal diagnosis for the patient?
4. An AIDS patient is admitted for treatment of congestive heart failure (CHF). He has a history of coronary artery bypass grafting (CABG) and was found to have HIV infection from a blood transfusion given at that time. His HIV was diagnosed a year ago, when he was found to have Kaposi's sarcoma of the skin, which is still present. He was treated with Lasix for the CHF and discharged. The appropriate codes include:
a. 042, 176.0, 428.0, V45.81
b. 428.0, V08, 176.0, V45.81
c. 428.0, 042, 176.0, V45.81
d. V08, 428.0, V45.81
5. A patient with a history of IV drug abuse presents for elective HIV testing. She is asymptomatic at the present time but wishes to know her HIV status. What are the appropriate diagnosis codes?
a. V72.6, 305.93
b. V73.89, V69.8
c. V65.44, V01.79
d. V72.6, V08
6. A patient with a history of HIV-related Cryptococcal meningitis presents seeking counseling concerning her treatment plan. How would the case be coded?
a. V65.44, 117.5, 321.0
c. 042, 117.5, 321.0
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (http://www.ingenix.com/). Ingenix is a leader in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic for ICD-9-CM is published quarterly by the AHA.
1. d: The dementia is an HIV-related condition, so code 042 should be sequenced as principal diagnosis. Code 294.10, Dementia in conditions classified elsewhere (without mention of behavioral disturbance), is more specific than code 294.8.
2. c: Acute nephritis should be sequenced as the principal diagnosis because there is no clear statement that the nephritis is HIV related. Code 042 should be sequenced as a secondary condition.
3. a: Code V08 for asymptomatic HIV infection status should be sequenced as the principal diagnosis. The patient did not receive counseling and has been diagnosed with positive HIV status, not merely HIV exposure.
4. c: The reason for the admission is the CHF, which is unrelated to the HIV disease. Code 428.0 should be sequenced as the principal diagnosis. Kaposi's sarcoma is still present; codes 042 and 176.0 should be assigned, along with V45.81 for the history of coronary artery bypass grafting.
5. b: The patient is being screened for HIV but has not received HIV counseling. V73.89 should be sequenced as the principal diagnosis and V69.8 for the high risk group status. Actual contact with HIV is not known so code V01.7 is not appropriate. The drug abuse is noted to be in the past as well; code 305.93 is also inappropriate.
6. b: The patient has fully developed AIDS so code 042 is appropriate. The meningitis is stated as a past history and no longer present so codes 117.5 and 321.0 are inappropriate. Code V65.44 is only to be assigned for discussion of negative HIV testing or education and instruction on HIV prevention.