Billing and Coding for HIV Services Financial Disclosure This speaker does not have any financial relationships with commercial entities to disclose. This speaker will not discuss any off-label use or investigational product during the program. Mentimeter Polling Go to www.menti.com and use the code 98 32 21 1
Outline Differentiating HIV infection from AIDS Coding for common HIV related inpatient diagnoses ICD 10 codes for HIV prevention including HIV preexposure prophylaxis (PrEP) What is HIV? Virus that causes HIV infection AIDS is the most advanced stage of HIV infection HIV is spread through contact with blood or body fluids of a person with HIV Antiretroviral therapy is the use of medications to treat HIV infection Lab Markers of HIV Infection AKA: Viral load 2
Opportunistic Infections People with a healthy immune system can fight off many infections and cancers People with advanced HIV have a weak immune system that can make them prone to certain infections and cancers that are unusual in healthier people These are called opportunistic infections because they take advantage of the person s weak immune system CDC. MMWR Morbid Mortal Wkly Rep. 2008;57(RR-10) HIV vs AIDS HIV infection present (Z21) No symptoms or diagnoses that indicate AIDS Can progress to AIDS AIDS disease due to virus (B20) AIDS defining condition CD4 count < 200 or CD4% < 14, ever Once AIDS diagnosed, should be B20 always 3
HIV vs AIDS HIV (Z21) HIV Infection HIV positive HIV Known HIV HIV Virus HIV Status HIV Test Positive HIV Infection, Asymptomatic AIDS (B20) AIDS AIDS related complex [ARC] AIDS related conditions HIV infection, symptomatic Rapid HIV Tests Preliminary results only Must do confirmatory testing to make sure not a false positive test 4
HIV Testing Algorithm https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6224a2.htm Example Ralph is a 42 year old man who has sex with other men. He returns to clinic to discuss the results of his HIV test which was done last week. The patient is informed he is HIV positive (asymptomatic). The provider counsels the patient and explains which it means to have HIV, safer sex practices to prevent HIV transmission and the role and rationale of HIV medication therapy. Z21 Asymptomatic HIV Z20.51 High risk homosexual behavior Example Karen sees her provider to discuss the results of her positive HIV test done last week. She has lost 15% of her body weight over the last 3 months (wasting) and has oral thrush (oral candidiasis). The provider counsels the patient and explains which it means to have HIV, safer sex practices to prevent HIV transmission and the role and rationale of HIV medication therapy B20 AIDS/Symptomatic HIV B22.2 HIV disease resulting in wasting syndrome B37.0 Candidal stomatitis 5
Case 1 (Menti) 37 year old man with HIV infection returns for follow-up of HIV infection. Doing well on his antiretroviral regimen of Triumeq. CD4 count now 569 (32%) and HIV viral load suppressed < 20 copies/ml. No clinical illness noted during current encounter. Do you have enough information to know if this patient should be coded Z21 or B20? Case 19 year old man admitted with fever, chills and visible oral thrush. Tested positive for HIV infection with CD4 count 112 (11%) and his HIV viral load is 250,000 copies/ml. Would you code Z21 or B20? Case 3 (menti) 25 year old woman admitted for labor in 3 rd trimester found to be HIV infected on rapid screen. No prior prenatal care. Risk factors for HIV infection include intravenous heroin use and unprotected sex with a man with known HIV. Confirmatory test for HIV is pending. Currently asymptomatic with no signs or symptoms to suggest AIDS diagnosis. What would you code? 6
Possible ICD 10 Codes R75 - Inconclusive laboratory evidence of human immunodeficiency virus [HIV] Need the confirmatory test to be sure HIV present Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus Z72.51 High risk heterosexual behavior O99.323 Drug use complicating pregnancy, third trimester ICD 10 Codes for Sexual Risk Behavior ICD 10 Code Description Use for Z72.51 High risk heterosexual behavior HIV, STD screening Z72.51 High risk homosexual behavior HIV, STD screening Z72.53 High risk bisexual behavior HIV, STI screening Other ICD 10 Codes Possible for Opioid Use NASTAD. Billing Coding Guide for HIV Prevention: PrEP, Linkage and Screening Services. Available at https://www.nastad.org/resource/billing-coding-guide-hiv-prevention. 7
R75 Inconclusive Lab Evidence of HIV Infection Babies will have indeterminant testing for HIV as they will have antibody from the mother for a period of time after birth Final confirmation of the baby s HIV status often cannot be determined for several months Example An woman with HIV infection presents to the pediatric infectious disease clinic for antiretroviral therapy follow-up for her 2 month old baby. The physician documents an expanded problem focused history and performs a brief exam. Upon review of the lab results which are inconclusive for HIV infection in the baby but show mild abnormalities attributed to medication use, the physician makes the decision to modify the antiretroviral medication. A revised treatment plan is discussed and the physician advises the mother to return with the baby in 1 month. R75 Inconclusive Lab Evidence of HIV Infection Z20.6 Contact with and (suspected) exposure to HIV Z79.899 High risk medication use Case 4 (menti) 28 year old woman born with HIV infection and a history of AIDS is admitted for labor in her 3 rd trimester. She currently is doing well from an HIV standpoint with CD4 589 (40%) and HIV viral load fully suppressed < 20 copies/ml. Pregnancy has been uncomplicated. STD screen was negative 3 weeks ago. What ICD 10 codes would you use? 8
Appropriate ICD 10 Codes O98.7 HIV disease complicating pregnancy, childbirth and the puerperium B20 (AIDS) Case 19 year old man presents for evaluation after having unprotected sex with a male stranger and asks for an HIV test. He returns in one week for the test result which is negative. Counseling regarding safer sex practices done. Condoms provided. Possible ICD 10 codes First visit Z11.4 Encounter for screening for HIV Z72.52 High risk homosexual behavior Second visit Z71.1 HIV counseling, Z72.52 high risk homosexual behavior What About HIV Prevention? HIV Pre-Exposure Prophylaxis (PrEP) Use of HIV drugs to prevent acquisition of HIV infection in people who are at high risk Requires screening for sexually transmitted diseases, hepatitis B, kidney disease, and HIV Monitoring for safety of tenofovir/emtricitabine (Tenofovir ) 9
Possible ICD10 Codes for PrEP Z20.5. Contact with (and suspected exposure to) viral hepatitis. Hepatitis Screening NASTAD. Billing Coding Guide for HIV Prevention: PrEP, Linkage and Screening Services. Available at https://www.nastad.org/resource/billing-coding-guide-hiv-prevention Code Sequencing Opportunistic infection codes are assigned as the secondary diagnoses if supported by medical record documentation B20 AIDS) B59 Pneumocystosis If HIV-2 illness is present B20 (AIDS) B97.35 (HIV, type 2 [HIV 2]) Common OI Codes Pneumocystosis (PCP or PJP) PCP pneumonia B59 Kaposi s sarcoma (C46.1) Can be more specific regarding location (examples) KS of unspecified lung C46.50 KS of GI tract C46.4 Candidal esophagitis B37.81 Candidal stomatitis B37.0 10
Other Situations Ben has a history of AIDS and has osteoporosis thought due to long term tenofovir (drug) use who presents with a pathologic fracture of his left leg. How could you code this encounter? M80.852A Other osteoporosis with current pathological fracture, left femur, initial encounter B20 AIDS Z79.899 High risk medication use Summary HIV (Z21) is asymptomatic HIV, while B20 indicates symptomatic HIV or a low CD4 count which indicates risk of opportunistic infection Once someone has a B20 diagnosis, Z21 or R75 codes should not be used HIV diagnosis is primary, with OI codes secondary Unless being seen for some other reason (for example pregnancy by OB) 11