a patient has an inconclusive hiv serology test. report icd-10-cm code of:

by Dr. Garnett Wilderman 8 min read

2022 ICD-10-CM Diagnosis Code R75: Inconclusive …

20 hours ago Inconclusive laboratory evidence of human immunodeficiency virus [HIV] 2016 2017 2018 2019 2020 2021 2022 Billable/Specific Code. R75 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Inconclusive laboratory evidence of human immunodef virus. >> Go To The Portal


Inconclusive laboratory evidence of human immunodeficiency virus [HIV] R75 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM R75 became effective on October 1, 2021.

What is the ICD 10 code for HIV test?

HIV Screening CPT and ICD -10 Codes TEST PRODUCT PTEST RODUCT Code Rapid Test Modifier Description 86689 Antibody; HTLV or HIV antibody, confirmatory test (e.g, Western Blot) 86701 92 Antibody; HIV-1 86702 92 Antibody; HIV-2 86703 92 Antibody; HIV-1 and HIV-2, single assay 87534 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1 ...

What is the CPT code for HIV counseling?

The HIV counseling code (Z71.7) may be used if counseling is provided for patients with positive test results. When a patient believes that he/she has been exposed to or has come into contact with the HIV virus, report Z20.6.

What if the documentation states only that the patient is HIV positive?

If the physician documentation states only that the patient is HIV positive, has HIV, or an HIV infection, a query would be required for clarification. Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question.

How do you code HIV as an unrelated condition?

If HIV patient met with an accident and admits the hospital then it’s an unrelated condition, in this case the primary diagnosis code will be unrelated condition, secondary diagnoses code will HIV (B20) and followed by any HIV related condition. The sequencing of code will be in below order.

What is the code for inconclusive HIV test?

Code 795.8 was intended for inconclusive HIV test results, whereas code 044.9 was intended for asymptomatic HIV infection (or a statement of "HIV positive").

What is the ICD-10-CM code for HIV?

ICD-10-CM Code for Human immunodeficiency virus [HIV] disease B20.

What is the difference between B20 and Z21?

Once a patient is coded to B20, they will always have B20 coded on their record; they will never go back to being coded using the asymptomatic code Z21. Code Z21 is used for patients who are asymptomatic, meaning they are HIV positive but have never had an HIV-related condition.

What is ICD-10 code R75?

ICD-10 code: R75 Laboratory evidence of human immunodeficiency virus [HIV]

What does the ICD-10 code B20 mean?

ICD-10 Coding: Diagnosis of B20 (HIV)

When do you code B20 and Z21?

Following ICD-10 guidelines, if a patient has or has had an HIV related condition, use B20 AIDS. If the patient has a positive HIV status, without symptoms or related conditions, use Z21.

What is diagnosis code Z11 4?

The description for diagnosis code Z11. 4 is “Encounter for screening for human immunodeficiency virus [HIV].

What is code Z71 7?

ICD-10-CM Code for Human immunodeficiency virus [HIV] counseling Z71. 7.

What is the ICD-10 code for STD screening?

ICD-10 code Z11. 3 for Encounter for screening for infections with a predominantly sexual mode of transmission is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

What is the sequence for HIV?

Sequencing. The proper sequencing for HIV depends on the reason for the admission or encounter. When a patient is admitted for an HIV-related condition, sequence B20 Human immunodeficiency virus [HIV] disease first, followed by additional diagnosis codes for all reported HIV-related conditions. Conditions always considered HIV-related include ...

What condition must be confirmed to select the code?

In the inpatient setting, HIV is the only condition that must be confirmed to select the code. All other conditions documented as “probable,” suspected,” likely,” “questionable,” “probable,” or “still to rule out” are coded as if they exist in the inpatient setting. Dx. Sequencing. The proper sequencing for HIV depends on the reason for ...

Is HIV a diagnosis?

HIV infection/illness is coded as a diagnosis only for confirmed cases. Confirmation does not require documentation of a positive blood test or culture for HIV; the physician’s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient. In the inpatient setting, HIV is the only condition ...

What is the principal diagnosis for HIV?

Patient with HIV disease admitted for unrelated condition. If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the principal diagnosis.

How many codes are needed for severe sepsis?

The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection.

How long can you use a sequela code?

There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: 1. Scar formation resulting from a burn.

When should sepsis be assigned first?

If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn't develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes. 5) Sepsis due to a postprocedural infection.

Can R65.2 be assigned as a primary diagnosis?

A code from subcategory R65.2 can never be assigned as a principal diagnosis. When severe sepsis develops during an encounter (it was not present on admission), the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses.

Is the acute phase of an illness or injury that led to the sequela coded as confirmed?

The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes).

What is the late phase of HIV?

One or more indicator diseases, depending on laboratory evidence of hiv infection (cdc); late phase of hiv infection characterized by marked suppression of immune function resulting in opportunistic infections, neoplasms, and other systemic symptoms (niaid). rheumatoid arthritis ( M05.-)

What are the most common infections in patients with aids?

Patients with aids are especially susceptible to opportunistic infections (usually pneumocystis carinii pneumonia, cytomegalovirus (cmv) infections, tuberculosis, candida infections, and cryptococcosis), and the development of malignant neoplasms (usually non-hodgkin's lymphoma and kaposi's sarcoma).

What does the title of a manifestation code mean?

In most cases the manifestation codes will have in the code title, "in diseases classified elsewhere.". Codes with this title are a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code.

What is CD4 positive?

An acquired defect of cellular immunity associated with infection by the human immunodeficiency virus (hiv), a cd4-positive t-lymphocyte count under 200 cells/microliter or less than 14% of total lymphocytes, and increased susceptibility to opportunistic infections and malignant neoplasms.

What is Z16.- code?

code to identify resistance to antimicrobial drugs ( Z16.-) A disease caused by human immunodeficiency virus (hiv). People with acquired immunodeficiency syndrome are at an increased risk for developing certain cancers and for infections that usually occur only in individuals with a weak immune system.

What is immunodeficiency syndrome?

Clinical Information. A disease caused by human immunodeficiency virus (hiv). People with acquired immunodeficiency syndrome are at an increased risk for developing certain cancers and for infections that usually occur only in individuals with a weak immune system.

What is the asymptomatic code for HIV?

Once a patient is coded to B20, they will always have B20 coded on their record; they will never go back to being coded using the asymptomatic code Z21. Code Z21 is used for patients who are asymptomatic, ...

What is the Z21 code?

Code Z21 is used for patients who are asymptomatic, meaning they are HIV positive but have never had an HIV-related condition. Once that patient experiences an HIV-related condition, the Z21 code is no longer appropriate.

Can HIV be coded?

HIV is one of three conditions that cannot be coded based on the documented terminology, “possible, probable, or suspected,” or any other similar terminology. It is not required that any form of testing be documented, such as a positive serology test.