Q: “On the HIV codes, when do you use the Z code versus the B code?
Would you code the patient as being active if they have history of HIV?”
A: When we start looking at the AIDS and HIV codes, we originally received this question
that came asking, “When do we use that Z code versus when do we use the 042 in ICD-9?”
So we went update it for ICD-10.
I’m reiterating some of the information that Tammy and Alicia covered when they covered
this topic back in August, but I looked at it from a little bit different perspective.
You’ll find I’m huge on citing my sources, so I wanted to give you where I found the
information that helped me make my decision in when do I use the Z code, the Z21 versus
the B20.
When we first start looking at HIV, the important thing to understand here is that a patient
at this point in time cannot have a history of HIV, it’s not possible.
We do not yet have a cure for HIV.
Once the patient has HIV, they have HIV for life.
From a coding perspective, it simplybecomes do they have symptomatic HIV or do they have
asymptomatic HIV?
We’ll scroll down a little bit farther and we’re going to talk about how do we figure
out what constitutes asymptomatic, which is the Z21, versus what constitutes symptomatic,
which is B20.
It was funny because when we were looking at our answer sheets earlier today, Alicia
goes, “I love this little timeline thing, how do you get that?”
I said, “The CDC website” because that’s actually where this came from.
What I did is, if you didn’t know this, the Federal government, our Federal government
here in the United States has a website devoted to AIDS and HIV because for years it was so
rampant and it’s still a very large thing that we have to deal with.
They actually estimate that up to 18% of the population that has HIV has no idea that they
have HIV because they’re asymptomatic.
What they explained is that there are really three stages of HIV.
There’s the Acute Infection point where the person first gets infected and their body,
it’s a virus so it’s replicating constantly.
That’s that acute infection timeframe.
Usually, they might have some flu-like symptoms.
It’s going to be a bad flu, it’s not going to be, “Oh, that was a piece of cake.”
That’s kind of all the more they’re going to get.
They’re not going to know.
It’s not going to be any abnormal, crazy, “Oh, I must have HIV, that’s what this
is.”
Then, they fall into a period of what we call Clinical Latency.
That means that the virus is just there, doing its thing replicating, not making them sick
but continuing to spread throughout their bloodstream.
It’s reproducing at a lower level than that initial thing, but it’s still considered
active infection.
Both of these, we’re still talking about an asymptomatic patient.
They have not yet had a symptom related to their HIV.
When we talk about symptoms related to their HIV, CDC actually defines AIDS, their CD4
cells fall below 200 cells and that’s when it’s progressed to AIDS.
They actually go up to explain that it’s not just the CD4 blood counts, it’s actually
about whether or not a patient has had what we call an OI or an opportunistic infection.
Those first two stages, the acute infection, the clinical latency, we don’t have any
symptoms associated with those.
Yeah, they thought they had the flu, but it’s not necessarily asymptomatic, it’s not an
opportunistic infection.
When we start looking through here, the guidelines actually say, “OK, if they’ve not had
a symptom of HIV, they’re asymptomatic.”
Usually, the provider is going to call this HIV positive, known HIV, they have a history
of an HIV-positive test.
The important thing to note here is this is not where the provider uses the phrase AIDS,
and I did not put this in this note, but this was a question that I have had people ask
me as I’ve done trainings, this is not if a provider writes the word ARC (Aids-Related
Complex).
That’s actually a lot of providers in the infectious disease world will call it ARC
when the patient is first beginning to experience an opportunistic infection, which is an HIV-related
illness.
Notice both of these guidelines for symptomatic and asymptomatic revolve around: Has the patient
had, either currently or in the past an HIV-related illness?
If they’ve had an HIV-related illness, they get coded as symptomatic HIV.
The AIDS.gov website goes on to explain: An HIV-related illness is these Opportunistic
Infections (sometimes referred to as OI).
The AIDS.gov web address actually says there are 20 Opportunistic Infections that by default,
if you have a patient with known HIV, since the time of their diagnosis with HIV has had
one of these conditions, they have full-blown AIDS.
Period.
Once they have AIDS, they have AIDS for the rest of their life.
Once they go from that Z21, that asymptomatic status to having an Opportunistic Infection,
they move into the B20 world.
They stay in that B20 world for life.
Even if we treat that Opportunistic Infection and it goes away, things like... if you’ll
scroll a little farther up, it will give you that full list of B20.
When we talk about Opportunistic Infections, these are things that take advantage of the
patient’s weakened immune system.
I think about it as, it’s going to take a patient nearly to death’s door, and it
could potentially be fatal for them.
If we start looking at these, think about this.
Candidiasis of bronchi, trachea, esophagus, lungs, that’s a fungal infection down in
there.
A patient with AIDS or with HIV has a compromised immune system, they’re not going to be able
to fight off these infections as well as a normal healthy patient would.
By definition, if a patient has HIV, and they have or since the time of their diagnosis
has had one of these 20 conditions, they have AIDS, they have full-blown AIDS.
The most common question I get is, “Well, the doctor didn’t call it AIDS.”
If the doctor documents known HIV and then the history it says “history of invasive
cervical cancer.”
At a bare minimum, you need to be querying the provider and going, “Was that before
or after their HIV diagnosis?
Is it related?”
Because if it’s related, that patient has AIDS, they should be reported using B20.
That’s one of the things I see most frequently.
I see a lot of coders go, “Well, the doctor didn’t say that, the doctor just said this...”
It comes down to understanding the disease process and knowing these different pieces
to know what to look for in the record.
Because yeah, the doctor may have said down here HIV positive, but in the history they
may have said “HIV positive with a history of histoplasmosis.”
Well, I got news, histoplasmosis is almost always HIV-related.
You need to know when to ask the questions of your providers and by asking those questions,
you’re going to begin to – I know this sounds funny – you’re going to begin to
train most providers as to what needs to be there when they’re diagnosing AIDS and HIV.
Another common question I get is, “What if our doctor doesn’t know that they’ve
had one of these Opportunistic Infections and just write ‘HIV positive’ and I coded
it as a Z21.”
We already have that problem with the ICD-9 codes that we did before we went to ICD-10,
the same process is likely to occur.
If you’re not familiar with that process, when you report those codes to the insurance
company they’re looking at their files and they’re going, “Oh, but we showed that
this patient actually has AIDS.”
More than likely, what happens is you get a letter from the insurance company saying,
“According to our records, this is a patient with full-blown AIDS.
Please verify your documentation so that you know, “Oh!
We need to get clarification from the patient or from the patient’s past medical records,
but it looks like we need to adjust our diagnosis because they don’t really just have HIV,
they have full-blown AIDS.”
Oftentimes, is that the provider doesn’t know the nuances and the differences from
a coding perspective, because remember, coding and clinical don’t always match 100%.
We’ve got to come to that common language and explain how it’s different from a coding
perspective.
For AIDS and HIV, when we talk about B20 and Z21, it’s all about are they symptomatic
or asymptomatic, which comes down not to their blood cell counts but have they had an Opportunistic
Infection or HIV-related illness.
Laureen: Just a few clarifying questions that came in.
Lina is asking if the patient is being treated for cancer, we don’t need to report their
HIV status?
Chandra: I would disagree with that statement.
Every insurance company and actually the coding rules, the way that they have always been
explained to me, even if you look in the ICD-10 guidelines, HIV is the only condition that
is considered to always be clinically significant.
It’s expected to be reported on every encounter for every provider that sees that patient
from the time of diagnosis until the time they expire because it does factor in to so
many things and there’s such a high risk around transmission, but that is the one disease
that they track extremely closely.
I would encourage you to report it on any HIV patient that you see.
Laureen: Debbie said, “So, HIV is either asymptomatic or symptomatic, no personal history
of?”
Chandra: Correct; because we can’t cure it yet.
Laureen: Candy said “I’ve always heard that if the patient has HIV in their past
history, you always have to code for HIV.
Is that true?”
Chandra: Yes.
Because again, HIV never goes away.
At this point in time, it can’t be cured.
It can be controlled with medications especially if we catch it in the asymptomatic phase,
but once they have HIV, like I said because we don’t have a cure yet, they have HIV
for life.
It’s the one condition that’s always considered clinically significant, so it needs to be
reported any time that patient is seen.
The order simply changes depending on why they’re there.
If you have a patient coming in and this goes back to the ICD-10 guidelines, those Chapter
1 guidelines.
You have a patient coming in for an HIV-related illness, maybe they’re coming in for histoplasmosis,
maybe they’re coming in for a Kaposi sarcoma.
Those are things that are inherently HIV-related.
The guidelines tell you, “OK, the HIV has to go first.”
If they’re coming in for something completely unrelated, maybe they sprained their ankle,
“Oh, I sprained my ankle, I need you to take a look at my ankle,” but they find
out during the intake this patient is HIV positive.
They don’t have AIDS, they have HIV or if they did have AIDS, that still needs to be
reported but the main reason they were there was the ankle sprain, the HIV would be kind
of an “Oh, by the way,” at the end that we get put on there.