hiv-vo8 or 042
I'm getting very tripped up on an HIV case and need some help!
The patient is noted to have an undetectable viral load and no mention of a previous opportunistic infection.
The pt in all notes is stated to be HIV positive.
The patient presented with unsteady gait, falls documented as 'could be hiv related nueropathy'. This drops off because a few days in becomes septic (not poa).
There is also documented thrombocytopenia and "Thrombocytopenia is the single most common cytopenia in HIV pts".
This is coded to V08, but I think it should be 042-question is, does it require a query to clarify:
#1 Is this HIV disease?
#2 Were the presenting symptoms related to hiv related neuropathy?
Or does this automatically code to 042 given the current documentation?
Thanks!
The patient is noted to have an undetectable viral load and no mention of a previous opportunistic infection.
The pt in all notes is stated to be HIV positive.
The patient presented with unsteady gait, falls documented as 'could be hiv related nueropathy'. This drops off because a few days in becomes septic (not poa).
There is also documented thrombocytopenia and "Thrombocytopenia is the single most common cytopenia in HIV pts".
This is coded to V08, but I think it should be 042-question is, does it require a query to clarify:
#1 Is this HIV disease?
#2 Were the presenting symptoms related to hiv related neuropathy?
Or does this automatically code to 042 given the current documentation?
Thanks!
Comments
I would offer that it is a query opportunity. The documentation that you
offer does not warrant the capture of 042 at this point. There is a coding
clinic from 1st Quarter 1992, page 3 to 4 with the Classification of AIDS. I
have also heard that some states have mandates and guidance as well.
Good luck,
Mark
MARK LEBLANC, RN, MBA, CCDS
DIRECTOR CDI SERVICES
952-353-3505
m.leblanc@thewilshiregroup.net