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Official Authorized Addenda: Human Immunodeficiency Virus Infection Codes and Official Guidelines for Coding and Reporting ICD-9-CM

ICD-9-CM International Classification

of Diseases 9th Revision Clinical Modification

Volume 1

Update

Official Authorized Addenda: Human Immunodeficiency Virus

Infection Codes and Official Guidelines for

Coding and Reporting

ICD-9-CM

(Revision No. 3)

Effective October 1, 1994

Note: Replaces Previous Classification Effective October 1, 1991

FOR MORBIDITY PURPOSES ONLY


The following CDC staff member prepared this report:

Perrianne Lurie, M.D., M.P.H.

Division of Health Care Statistics National Center for Health Statistics


Notice

Pages 16-19 of the following report are reprinted in the MMWR series of publications so that the material may be readily accessible to the public health community.

Summary

This document contains changes to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for HIV infection and disease and includes guidelines for coding and reporting these conditions. The ICD-9-CM is the diagnosis classification system used for morbidity coding in U.S. health-care facilities. The simplification of the classification structure and the addition of guidelines should facilitate greater coding accuracy.

INTRODUCTION

This addendum for Volume 1 of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is reported by the World Health Organization Collaborating Center for Classification of Diseases for North America and the Morbidity Classification Branch, Division of Health Care Statistics, at CDC's National Center for Health Statistics.

This addendum replaces the addendum containing the codes for human immunodeficiency virus (HIV) infection (042.0-044.9) that became effective October 1, 1991. This addendum is effective October 1, 1994, and is the third revision of codes for the classification of HIV infection. This addendum reflects the evolving conceptual framework for HIV-related illnesses and presents a simplified coding structure for these conditions. These changes will be effective only for morbidity purposes; the cause of death codes are unchanged. * Modifications to these ICD-9-CM codes do not affect the CDC surveillance definitions for HIV disease.

This revised addendum contains the following changes:

  • The current 042-044 series of codes has been replaced with a single code, 042, for HIV disease.

  • A new code, V08, has been created for asymptomatic HIV infection.

  • Code 795.8 has been deleted and a new code, 795.71, Inconclusive sero- logical findings for Human Immunodeficiency Virus {HIV}, has been created. This code will include inconclusive HIV test findings in infants.

  • Additional instructional notes have been added to assist in proper code sequencing.

  • HIV-specific official coding guidelines have been created to assist persons who assign codes in the selection and sequencing of codes for HIV infection, disease, and related conditions.

BACKGROUND

The increasing incidence of HIV infection and advances in medical knowledge about the spectrum of illnesses caused by this virus have created demand for continued modifications to the classification. The current modifi- cations will simplify the coding of HIV-related illnesses and should improve the accuracy of reporting, allowing public health officials, clinical researchers, and agencies that finance health care to monitor more reliably the diagnoses of acquired immunodeficiency syndrome (AIDS) and other manifes- tations of HIV infection.

When the original interim classification was issued on October 1, 1986, periodic revisions were anticipated. The first such revision occurred in 1987 and reflected the change in terminology from HTLV-III/LAV to HIV, charac- terizing the causative agent of AIDS. In the 1991 revision, several HIV- related conditions were added to the lists of inclusions under the 042-044 series of categories.

The 042, 043, and 044 categories were originally created to distinguish AIDS (042) from AIDS-related complex (ARC) (043) and other HIV disease (044). These distinctions among the ICD-9-CM categories are no longer clear-cut, and the three-digit categories no longer denote separate clinical entities. Also, demands for additions to the lists of inclusion terms continue to grow, and it has become impossible for these lists to remain as current as medical reports. In addition, both the lack of clear guidelines for the sequencing of the HIV and manifestation codes and the restrictions on persons who assign codes to use only a single code from the 042-044 series have created confusion and inconsistent coding practices in the field.

Codes 795.8 and 044.9 have also caused confusion. Code 795.8 was intended for inconclusive HIV test results, whereas code 044.9 was intended for asymp- tomatic HIV infection (or a statement of "HIV positive"). However, both of these codes have been widely misused because of the lack of clear instruc- tions and guidelines.

Therefore, the current 042-044 series of codes has been replaced with a single code, 042, Human Immunodeficiency Virus {HIV} Disease, to be used for all symptomatic (or previously symptomatic) HIV infections. This code includes all cases of physician-diagnosed AIDS, whether asymptomatic (e.g., a diagnosis based on CD4+ T-lymphocyte criteria alone) or symptomatic. In addition, a new code, V08, has been created for asymptomatic HIV infection. The new code, 795.71, is applicable only to those patients who test positive on a preliminary screening test, but whose HIV infection status is not yet confirmed. Infants who test positive on certain serologic tests that may also reflect the serostatus of the mother should be coded as 795.71. In addition, a set of HIV-specific official coding guidelines has been developed to help ensure proper code selection and sequencing.

STRUCTURE OF THE CLASSIFICATION

The classification for symptomatic HIV infection consists of a single, three-digit ICD-9-CM code -- code 042, found in Chapter 1, Infectious and Parasitic Diseases, of the ICD-9-CM. This classification places HIV infection at the beginning of the section on viral diseases. Multiple coding of all listed manifestations of HIV infection is required. The new code for asymp- tomatic HIV infection, V08, is found in the Supplementary Classification of Factors Influencing Health Status and Contact with Health Services; the code for inconclusive serologic tests for HIV, 795.71, is found in Chapter 16, Signs, Symptoms, and Ill-Defined Conditions.

HOW TO USE THIS CLASSIFICATION

The following instructions for persons who assign codes will help to ensure more accurate coding practices:

  • To use these codes correctly, the physician must provide complete information about the manifestations of the HIV-related illnesses and their relationship to HIV. Persons who assign codes should not assume that conditions are HIV related unless the physician so indicates.

  • All manifestations of HIV infection must be coded. The person who assigns codes should refer to Volume 2 of the ICD-9-CM, the Alphabetic Index, to determine the proper codes for these conditions.

  • Selection of the principal diagnosis should be based on the information contained in the individual patient record. The 042 code should be listed as the principal diagnosis when a patient is admitted to a health-care facility for an HIV-related condition. Additional codes for all HIV- related conditions should be assigned as other diagnoses.

  • A patient with HIV disease may be admitted to a health-care facility for an unrelated condition. In these cases, the unrelated condition should be the principal diagnosis, with the 042 code listed as an additional diagnosis, followed by the codes for the manifestations of the HIV disease.

  • Asymptomatic HIV infection should be coded as V08 and not as 042. However, patients who have a history of symptomatic HIV infection, but who are currently asymptomatic, should be coded as 042.

HIV-2 ILLNESS

The classification assumes that conditions classified as code 042 are the result of infection with HIV-1 unless an additional code for HIV-2 is included in the record. Therefore, in cases of illness resulting from infection with HIV-2, the physician must specify that HIV-2 is the causative agent, and the coder must list the code for the HIV-2 infection, 079.53, as an additional diagnosis.

  • Cause-of-death coding is done using the International Classification of Diseases, Ninth Revision (ICD-9), which is not modified between revisions. The ICD-9-CM, which is used for morbidity purposes, is updated annually.


ICD-9-CM OFFICIAL AUTHORIZED ADDENDA FOR HUMAN

IMMUNODEFICIENCY VIRUS INFECTION CODES

Volume 1

042 Human Immunodeficiency Virus {HIV} Disease

Acquired immune deficiency syndrome Acquired immunodeficiency syndrome AIDS AIDS-like syndrome AIDS-related complex ARC HIV infection, symptomatic

Use additional codes to identify all manifestations of HIV disease.

Use additional code to identify HIV-2 infection (079.53), if present.

Excludes: asymptomatic human immunodeficiency virus {HIV}

infection (V08) inconclusive serologic findings for human immunode-

ficiency virus {HIV} infection (795.71)

795.71 Inconclusive serological findings for human immunodeficiency virus

{HIV}

Excludes: asymptomatic human immunodeficiency virus {HIV}

infection status (V08) human immunodeficiency virus {HIV} disease (042)

V08 Asymptomatic human immunodeficiency virus {HIV} status

human immunodeficiency virus {HIV} positive (status)

human immunodeficiency virus {HIV} infection (asymptomatic)

Excludes: human immunodeficiency virus {HIV} disease (042)

inconclusive serological findings for human immunode-

ficiency virus {HIV} (without diagnosis) (795.8) symptomatic human immunodeficiency virus {HIV}

infection (042)


OFFICIAL GUIDELINES FOR CODING AND REPORTING *

10. HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTIONS

10.1 Code only confirmed cases of HIV infection/illness.

This is an exception to guideline 1.8 which states "If the diagnosis documented at the time of discharge is qualified as 'probable,' 'suspected,' 'likely,' 'questionable,' 'possible,' or 'still to be ruled out,' code the condition as if it existed or was established..."

In this context, "confirmation" does not require documentation of positive serology or culture for HIV; the physician's diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient.

10.2 Selection of HIV code

042 Human Immunodeficiency Virus {HIV} Disease

Patients with an HIV-related illness should be coded to 042, Human Immunodeficiency Virus {HIV} Disease.

V08 Asymptomatic Human Immunodeficiency Virus {HIV} infection

Patients with physician-documented asymptomatic HIV infections who have never had an HIV-related illness should be coded to V08, Asymptomatic Human Immunodeficiency Virus {HIV} Infection.

795.71 Nonspecific Serologic Evidence of Human Immunodeficiency Virus

{HIV}

Code 795.71, Nonspecific serologic evidence of human immunode- ficiency virus {HIV}, should be used for patients (including infants) with inconclusive HIV test results.

10.3 Previously diagnosed HIV-related illness

Patients with any known prior diagnosis of an HIV-related illness should be coded to 042. Once a patient had developed an HIV-related illness, the patient should always be assigned code 042 on every subsequent admission. Patients previously diagnosed with any HIV illness (042) should never be assigned to 795.71 or V08.

10.4 Sequencing

The sequencing of diagnoses for patients with HIV-related illnesses follows guideline 2 for selection of principal diagnosis. That is, the circumstances of admission govern the selection of principal diagnosis, "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

Patients who are admitted for an HIV-related illness should be assigned a minimum of two codes: first assign code 042 to identify the HIV disease and then sequence additional codes to identify the other diagnoses. If a patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV-related conditions.

If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the principal diagnosis. Other diagnoses would be 042 followed by additional diagnosis codes for all reported HIV-related conditions.

Whether the patient is newly diagnosed or has had previous admissions for HIV conditions (or has expired) is irrelevant to the sequencing decision.

10.5 HIV Infection in Pregnancy, Childbirth and the Puerperium

During pregnancy, childbirth or the puerperium, a patient admitted because of an HIV-related illness should receive a principal diagnosis of 647.8X, Other specified infectious and parasitic diseases in the mother classifiable elsewhere, but complicating the pregnancy, childbirth or the puerperium, followed by 042 and the code(s) for the HIV-related illness(es). This is an exception to the sequencing rule found in 10.4 above.

Patients with asymptomatic HIV infection status admitted during pregnancy, childbirth, or the puerperium should receive codes of 647.8X and V08.

10.6 Asymptomatic HIV Infection

V08 Asymptomatic human immunodeficiency virus {HIV} infection, is to be applied when the patient without any documentation of symptoms is listed as being "HIV positive," "known HIV," "HIV test positive," or similar terminology. Do not used this code if the term "AIDS" is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use 042 in these cases.

10.7 Inconclusive Laboratory Test for HIV

795.71 Inconclusive serologic test for Human Immunodeficiency Virus

{HIV}

Patients with inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness may be assigned code 795.71.

10.8 Testing for HIV

Code V72.6 Laboratory examination, should be assigned for patients seen only for HIV testing. This code does not include any counseling given during the encounter for the laboratory test; an additional code of V65.44, HIV counseling, should be used to indicate that counseling was given. (Test results are not available during these encounters.)

When the patient returns to be informed of his/her HIV test results, V72.6 is not used. If the results are negative, use code V65.44, HIV counseling. If the results are positive, code V08, Asymptomatic HIV infection, should be used unless the patient has symptoms of HIV disease. If the test result is positive and the patient has an HIV- related illness, code 042, HIV disease, should be used.

  • The ICD-9-CM Official Guidelines for Coding and Reporting is a separate document published by the Government Printing Office. It contains nine previous sets of coding guidelines that are not specific to HIV infection. The Official Guidelines are updated periodically and the following changes are part of the 1994 update.




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