Human Immunodeficiency Virus Infection Documentation Guide
Retroviral infection affecting the immune system, managed with antiretroviral therapy.
ICD-10 Codes: B20, Z21
Common Symptoms
- Often asymptomatic on ART
- Fatigue
- Lymphadenopathy
- Opportunistic infections
- Weight loss
Key Documentation Elements
- CD4 count and trend
- HIV viral load (copies/mL)
- Current ART regimen
- ART adherence assessment
- Opportunistic infection prophylaxis status
- Preventive care and screening completion
Documentation Challenges
- Documenting CD4 count and viral load trends
- Recording ART regimen adherence and tolerability
- Capturing opportunistic infection prophylaxis status
- Tracking preventive care (vaccinations, screening)
Billing Considerations
- B20 for HIV disease vs Z21 for asymptomatic status
- Documentation of complications for HCC capture
- Complex chronic care management billing
- ART management justifying high-complexity E&M
Frequently Asked Questions
What is the difference between B20 and Z21 coding?
B20 codes HIV disease (symptomatic or with complications). Z21 codes asymptomatic HIV status. Scribeable selects the appropriate code based on your documented clinical findings and patient status.
How does Scribeable help with HIV management documentation?
Scribeable captures CD4 counts, viral loads, ART regimen details, adherence assessment, and prophylaxis status from your encounter to generate comprehensive HIV management notes.