Topic: HIV
Scenario: 65 year old hemophiliac presents with poor appetite, difficulty swallowing, and weight loss
History and Physical:
HPI: Recently moved to the US; reports poor appetite and sore throat over the last 3 months; reports being unable to get out of bed for a week; at patient’s last office visit, his lab work was positive for HIV; patient was non-compliant with follow-up stating he had moved and has not sought out a new primary care physician
- PMH: depression, hemophilia, HIV
- Home Medications: multivitamin, Fe supplement
- PE: Cachectic, marked alopecia, muscle wasting, lungs are diminished throughout, tachycardia, white patches noted in mouth
- Labs: WBC 3.5 Hgb 9.1, HIV positive, CD4 count 141, viral load ordered
- CXR: negative
Speech Consult: passed swallow test
RD consult: weight loss of 25 lbs., BMI 17.2, meets criteria for severe protein calorie malnutrition
EGD report: candidiasis noted throughout esophagus, biopsied
Discharge Summary: severe protein malnutrition, HIV +, hemophilia, thrush, ID consult as outpatient for antiretroviral therapy
Question: Are there query opportunities based on the scenario stated above?
Discussion:
HIV disease/AIDS: An HIV-positive patient with a past or present occurrence of either of the following:
- Absolute CD4 T-lymphocyte count < 200
- An AIDS defining condition
The CD4 count of an uninfected adult in good health is 500 to 1500
UASI Recommends:
Query for:
- Query for clarification for HIV disease ( B20) vs asymptomatic HIV ( Z21)
- Query for linkage of EGD report to HIV ( thrush vs candida esophagitis)– CDI can NOT assume any relationship between diagnoses and HIV
Documentation without clarification:
Principal diagnosis: E43-Unspecified severe protein calorie malnutrition
Secondary diagnoses: D66 Hereditary factor VII deficiency, Z21 Asymptomatic HIV, B370 Candidal stomatitis
DRG: 640 Misc. Disorders of nutrition, metab, fluid/electrolytes w MCC, RW: 1.214, GMLOS: 3.3, SOI/ROM: 3/3
Documentation with clarification:
Principal diagnosis: B20- HIV disease
Secondary diagnoses: D66 Hereditary factor VII deficiency, B37.81 Candidal esophagitis, E43 unspecified severe protein calorie malnutrition
DRG 974 HIV with major related condition with MCC, RW: 2.6739 GMLOS: 6.3, SOI/ROM: 4/4
CDI Educational Tips:
- AHA Coding Clinic, First Quarter 2019 , p.8
- The provider should be queried if the documentation is unclear on whether the condition is related to HIV
- ICD 10 OCG Section I.C.1.a.2.f:
- Patients with known HIV-related illness should always be coded to B20. Code confirmed cases to B20 and never to Z21 ( asymptomatic)
- When AIDS is documented or if the patient is being treated for any HIV related illness use B20
- Asymptomatic HIV (Z21) has a significant impact on risk adjustment which impacts hospital ratings (https://health.usnews.com/health-care/best-hospitals/articles/faq-how-and-why-we-rank-and-rate-hospitals)
- Past medical records: Review previous records for an HIV related illness with prior coding of B20
Examples for coding Z21 and B20
Case Example | PDX | 2nd Codes |
Positive HIV test in patient who is asymptomatic | Reason for admission | Z21 |
Candidiasis 2/2 AIDS | B20 | B37.0 |
Herpes Zoster 2/2 HIV | B20 | B02.9 |
Acute appendicitis admitted for appendectomy, Kaposi’s sarcoma of skin 2/2 HIV, w total appendectomy | K35.80 | B20,C46.9,0DTJ4ZZ |
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.