(2026 guidelines)
TBH, this is the second attempt to put up this article. The first time I accidentally deleted it on the site
– and had not saved the word document. These things happen to those who let them – my fault
entirely. As the second go-round this one should be better :)
By better I mean briefer. More useful information in fewer words!
Only code B20 IF:
1. Was previously used on this client
2. Provider documents an HIV related disease, uses the words HIV disease or AIDS and client is
symptomatic.
DO NOT CODE B20, even in inpatient (is an exception to the inpt guidelines), if the provider is not
absolutely definite. “Suspected”, “Not ruled out”, “Probable” = no code at all. Unless states symptoms
– in those cases you can code the symptoms.
Code Z21 if all of the following are true:
1. client is HIV positive but asymptomatic
2. Doesn’t have a related illness
3. AND has NEVER been coded as B20. If you don’t know if the person has ever been coded with
B20, use Z21.
B20 is first code for any HIV or HIV related condition visit EXCEPT:
1. In Pregnancy. O98.7xxx goes first then either Z21 or B20 (and any HIV related illness), then as
normal.
2. In encounters for hemolytic-uremic syndrome. First is D59.31, then B20.
If visit is not HIV related, use B20 or Z21 and code the reason for the encounter first.
If a person is testing for HIV:
1. If asymptomatic use Z11.4. Can add any high-risk behavior codes
2. If symptomatic use the symptom codes followed by Z71.7
3. If results are negative at the follow-up code Z71.7
4. If results are inconclusive use R75
5. If positive use B20
HIV Medication codes:
1. If on antiretrovirals add Z79899 to either Z21 or B20
2. Use Z29.81 if the visit is to get medications before a possible exposure to HIV. Also code any risk
factors documented.
HIV related conditions are numerous. This link will open the NIH’s HIV information website. The list of
related conditions starts below the pictures.
I hope this helps you with HIV coding.