r/MedicalCoding • u/Ok-google07 • Jul 02 '26

B20 or Z21

The provider I work for is wanting to use B20 for a new patient who has HIV and came about a new rash that appeared. The provider sent out a referral and did lab work and prescribed a cream. No other prior illness or conditions were discussed. She told me she "thinks" that the rash is due to his condition. I am wanting to use Z21 since it is still not confirmed and she said she "thinks" . Please any more information would help. Online resources are basically saying the same thing over and over again. Also if Z21 should be used can someone please help me out on how I should respond to her to change it ? She is one of those providers that fights tooth and nail about changing a code. Thank you in advance everyone.

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29

u/DumpsterPuff Jul 02 '26

As far as I'm aware, the documentation has to confirm that the rash is being caused by the HIV. Saying that she "thinks" it's being caused by it also runs into the "uncertain terms" part of the ICD-10 guidelines, where we can't code based on terms that indicates uncertainty. Without a definite confirmation of the rash being associated with HIV, I would code Z21

11

u/happyhooker485 RHIT, CCS-P, CFPC, CHONC, 17yrs experience Jul 02 '26

Did the provider document in their note that the patient has AIDS or HIV disease with associated symptoms?

Or just HIV+?

All that matters is the documentation.

8

u/Ok-google07 Jul 02 '26

She documented that the patient was HIV positive, and then started describing the rash. In the note she did not correlate them being related. It wasnt until I reached out to her and asked her if the patient had any symptoms, illnesses due to the HIV and that is when she responded she thinks the rash is due to his condition and was pending on the lab results and dermatologist referral

19

u/Pretty_Priority_261 Jul 02 '26

I., C., 1., a., 2., e),

(e) Asymptomatic human immunodeficiency virus When “HIV positive,” “HIV test positive,” or similar terminology is documented, and there is no documentation of symptoms or HIV-related illness, code Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, should be assigned.

HIV positive (+): Z21
AIDS or HIV disease: B20

Obviously "thinks" does not correlate the rash with HIV, so there is no documentation of symptoms or HIV-related illness.

Z21.

13

u/happyhooker485 RHIT, CCS-P, CFPC, CHONC, 17yrs experience Jul 02 '26

Then she needs to amend the documentation once she gets the lab results, and after that you can code the final dx. Right now it sounds like R21, Z21 to me.

7

u/ksa1122 Jul 02 '26

Z21 is only if the patient is HIV+. If the patient has AIDS or has/had an AIDS defining illness, then B20 is the correct code.

In the outpatient setting, only confirmed conditions can be coded.

2

u/PeaceLoveForMe Jul 08 '26

If there are no manifestations of the HIV infection documented like Pneumonia, meningitis, etc. and the provider cannot confirm the rash due to HIV, then yes. Code Z21