HIV status

vanessa.falkoffvanessa.falkoff
in CDI Talk Archive
Happy New Year to you all.

Does anyone have an HIV query they can share?

Thanks in advance :)

Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Due to time constraints, brief response.


    Code only confirmed cases of HIV/AIDS, per official guidelines.

    Reference:


    Chapter 1: Infectious and Parasitic Diseases (001-139)
    a. Human Immunodeficiency Virus (HIV) Infections
    1) Code only confirmed cases
    Code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H.
    In this context, “confirmation” does not require documentation of positive serology or culture for HIV; the provider’s

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org




  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Please be aware HIV/AIDS reporting is subject to particular scrutiny - the Official Guidelines state that 'suspected' cases of HIV/AIDS are not coded as such. Please see the Chapter Specific Guidelines for HIV/AIDS for further guidance. (Only code confirmed cases).




    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    C. Chapter-Specific Coding Guidelines

    In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings. Please refer to Section II for guidelines on the selection of principal diagnosis.

    Chapter 1: Infectious and Parasitic Diseases (001-139)

    a. Human Immunodeficiency Virus (HIV) Infections

    1) Code only confirmed cases

    Code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H.
    In this context, “confirmation” does not require documentation of positive serology or culture for HIV; the provider’s
    diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient.


    ICD-9-CM Official Guidelines for Coding and Reporting
    Effective October 1, 2011
    Page 14 of 107



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org

  • tracy.boldttracy.boldt
    Thanks All for the clarification.
  • gwojogwojo
    edited May 2016
    You are absolutely correct Karen.
    This is exception to probable, possible on discharge summary. Physician should be queried.

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