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Monthly CDI Scenario Discussion – May 2020

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?


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 (
  • Past medical records: Review previous records for an HIV related illness with prior coding of B20

Examples for coding Z21 and B20

Case ExamplePDX2nd Codes
Positive HIV test in patient who is asymptomaticReason for admissionZ21
Candidiasis 2/2 AIDSB20B37.0
Herpes Zoster 2/2 HIVB20B02.9
Acute appendicitis admitted for appendectomy, Kaposi’s sarcoma of skin 2/2 HIV, w total appendectomyK35.80B20,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.