Q&A: HIV coding exception

Q: If documentation states, “probable HIV disease,” is that definitive enough to code?

A: In the instance of HIV, the terms “possible,” “probable,” “likely,” and “suspected” would not apply.  Per The Official Guidelines for Coding and Reporting:

C. Chapter-Specific Coding Guidelines

In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings. Please refer to Section II for guidelines on the selection of principal diagnosis.

1. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9

a. Human Immunodeficiency Virus (HIV) Infections

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.

So, in this situation you would only code if the provider confirmed the diagnosis. Conditions of HIV, COVID-19, Zika, and influenza must have provider confirmation to report. 

Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at dwilk@hcpro.com.