The Human Immunodeficiency Virus or HIV is a retrovirus that affects the human immune system and allows people become much more susceptible to infections and diseases. This virus found in body fluids (semen, vaginal fluids, blood and breast milk) of the infected person is passed from one person to another through sexual contact, prenatal transmission (infected pregnant women can transmit HIV to their babies during pregnancy, while delivering the baby during childbirth and during breastfeeding) and blood transfusion. Though HIV infection leads to the development of AIDS, it is possible that the patient may get infected with HIV without developing AIDS. In most cases, HIV infection progresses without proper treatment which will eventually develop into AIDS. HIV screening and diagnosis identifies the infection in the early stages, helps to slow down the rate at which the virus replicates and delays the development of AIDS. Proper medical coding of screening procedures on the medical claims is essential on the part of physicians or medical coding companies to ensure accurate documentation and appropriate reimbursement.
HIV Testing, Treatment and Importance of Early Diagnosis
HIV infection is typically diagnosed through a blood test that specifically screens for HIV virus. The common HIV test used is antibody screening test that screens for the antibodies that the patient’s body makes against HIV. There is another commonly used test that can detect both antibodies and antigen (part of the virus) and find recent infection earlier than the antibody screening test. This combination test can detect HIV within 3 weeks after exposure to the virus. There is also the rapid HIV test, an antibody screening test that can give quick results within 30 minutes or less. If the test result is found to be positive, the blood is re-tested several times to confirm the positive result. Once the test result is confirmed positive, several other tests are conducted to explore how the infection has progressed and decide the appropriate time to start the treatment. However, it is very important to consider the window period (time taken by the HIV virus to show up on the testing after infection).
HIV screening and testing guidance continues to evolve depending upon the changes in testing technology and methods to reach patients. The Centers for Disease Control and Prevention (CDC) has published the updated federal guidance on HIV screening and testing for physicians, nurses, administrators, clinical coordinators, program managers and laboratory personnel who test specimen.
Though there is no vaccine available for HIV/AIDS, efficient treatments are there to significantly improve patients’ general health and quality of life. An anti-HIV medication called post-exposure prophylaxis or PEP may stop infection if the person has been exposed to the virus within the last 72 hours. However, the person should take the treatment as soon as possible after getting infected with the virus. Treatment with antiretroviral drugs fights against the HIV infection and reduce the rate at which the virus spread to the body. Even though treatments are available to improve the quality of life, the treatment is more likely to be successful if the HIV infection is detected earlier.
A recent study published in the LANCET stresses that early diagnosis can save the lives of people and reduce onward transmission. It also points out that many people having HIV infection go undiagnosed. According to the Centers of Disease Control and Prevention (CDC), almost 1 in 7 (14 percent) among 1.2 million people in the United States are living with HIV infection without knowing that they are infected. In this study, general practices were encouraged to promote rapid HIV testing for their newly registered patients. Every patient diagnosed by this testing was successfully transferred to specialist care without any adverse events. Promotion of testing in general practices resulted in an increased rate of diagnosis and increased early detection of HIV. The study authors therefore recommended the implementation of HIV screening in general practices in areas with high incidence of HIV.
Reporting HIV Infection on Medical Claims
The following code is used when the finding is HIV positive status only without AIDS, and the patient has never been diagnosed with AIDS and never had any kind of AIDS-defining condition. This code must be assigned for confirmed HIV only and never for suspected, probable or possible cases.
- V08: Asymptomatic human immunodeficiency virus [HIV] infection status
You should use the following code if the patient is diagnosed with AIDS at present or was diagnosed with AIDS at any time in the past. Once assigned, this code must always be used on every subsequent encounter in case of both inpatient and outpatient visits.
- 042: Human Immunodeficiency Virus [HIV] Disease
The ICD-10 code for HIV is given below.
- B20: Human immunodeficiency virus [HIV] disease
If the encounter is for HIV-related condition, report the primary diagnosis with B20 followed by additional codes to report the HIV-related condition. If the encounter is for HIV-infected patient other than for HIV or an HIV-related condition, the reason for the encounter should be listed as primary diagnosis followed by B20. If it is documented that the patient is HIV-positive based on serology or culture, but does not have any symptoms, report this with the following code:
- Z21: Asymptomatic human immunodeficiency virus [HIV] infection status
When the patient is known to have been exposed to HIV, but the testing shows no positive result and the patient has no HIV symptoms, report it using the following code:
- Z20.6: Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
If the serology for HIV is inconclusive, the code to be used is
- R75: Inconclusive laboratory evidence of human immunodeficiency virus [HIV]
When the patient has AIDS, report B20 and never use Z21 or R75. If the HIV-patient is pregnant and the encounter is for HIV-related condition, the primary diagnosis should be reported using O98.7 (Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium) followed by B20 and codes for HIV-related illness. If the pregnant patient has asymptomatic HIV, report O98.7 with Z21.
For a patient who has come for HIV testing, use Z11.4 (Encounter for screening for HIV). Assign additional codes for any unknown high-risk behavior such as:
- Z72.51: High risk heterosexual behavior
- Z72.52: High risk homosexual behavior
- Z72.53: High risk bisexual behavior
If the patient has signs or symptoms while presenting for HIV screening, report the signs and symptoms. If counseling is provided during the encounter, use the code Z71.7 (HIV counseling) to report that. When the patient comes back for the results of the HIV screening and the results are found to be negative, report Z71.7.
Reporting HIV Screening Procedures
HIV screening is covered as a preventive service under the Affordable Care Act (ACA), if it is coded appropriately. The CPT codes used to report HIV screening for adolescents and adults are as follows:
- 86689: HTLV or HIV antibody, confirmatory test
- 86701: Antibody; HIV-1
- 86702: Antibody; HIV-2
- 86703: Antibody; HIV-1 and HIV-2, single assay
- 87389: Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result
- 87534: Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique
- 87535: Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique
- 87536: Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification
- 87537: Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique
- 87538: Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique
- 87539: Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification
The Centers for Medicare & Medicaid Services (CMS) covers standard or rapid HIV screening tests reported using the following HCPCS G codes:
- G0432: Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening
- G0433: Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening
- G0435: Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening
HIV screenings are covered for a maximum of three times per term of pregnancy in the case of pregnant Medicare beneficiaries when the diagnosis of pregnancy is known, during the third trimester and at labor.
However, you must report HIV screening for pregnant women with a primary diagnosis code V73.89 (Special screening for other specified viral disease) followed by a secondary diagnosis of either V22.0 (Supervision of normal first pregnancy), V22.1 (Supervision of other normal pregnancy), or V23.9 (Supervision of unspecified high-risk pregnancy).
If there is increased risk for HIV infection (11 full months must elapse between tests), the HIV screenings are covered once in a year. In order to specify increased risk for HIV with V73.89 as primary and V69.8 (Other problems related to lifestyle as secondary). In case of beneficiaries without increased risk factors, report HCPCS Level II codes with diagnosis code V73.89 only. HIV screening is not covered for patients with any known prior diagnosis of HIV-related illness.
To learn more about Coding for HIV we have written a new blog Coding for HIV and AIDS in ICD-10 – Important Clarifications on July 24,2017