Accurate HIV Coding Can Improve Patient Care

CDPHP supports the NYS Department of Health (DOH) initiative to remove barriers and combat the stigma associated with human immunodeficiency virus (HIV) testing, pre-exposure prophylaxis, and treatment. In 2018, the DOH updated HIV testing regulations, removing the requirement to obtain either written or verbal consent from patients. This change has helped to streamline access to HIV testing and has resulted in increased testing rates at regulated settings.

Accurate coding – especially making the distinction between screening and diagnosis coding – is also important to ensure that patients with HIV concerns receive optimal care and support. The following is a summary of the most frequently used codes and their appropriate application.

Screening Codes:

• Z11.4: For a healthy person who is being screened for HIV
• Z20.6: For a person who has not yet been diagnosed as having HIV or AIDS, but who has had contact with and (suspected) exposure to HIV
• Z71.7: For HIV counseling

Diagnosis Codes:

• Z21: For a person with asymptomatic HIV
• B20: For a person with symptomatic HIV, acquired immune deficiency syndrome (AIDS) with a CD4 count less than 200, or one who has an opportunistic infection present. (Note: once a person is identified as having any of the B20 criteria, his/her diagnosis should always be coded as B20, even if the CD4 count exceeds 200 or the opportunistic infection resolves.)
• O98.7: For the primary diagnosis of pregnancy in a woman with HIV

For additional support and information relating to HIV care, please contact the dedicated HIV RN specialist at CDPHP by calling (518) 641-3431.