![]() ![]() Vitals taken BP is elevated at 157/92.Height and weight are appropriate for age. Patient is an 81 year old male in no acute distress.Has history of essential hypertension and was prescribed metoprolol succinate once daily by PCP, but patient is not taking as he cannot afford it 2.No history of cerebrovascular disease.Regular physical activity includes walking, swimming, and golfing.Inferior wall MI one year ago, received thrombolytic therapy and experienced complete resolution of his symptoms.Smith requested evaluation for hypertension and cardiac clearance assessment for surgery 1. 81 year old male scheduled for a TURP in 5 days.Smith asked that you check my hypertension prior to my surgery.” Scenario 1: Hypertension / Cardiac Clearance ![]() The clinical concepts for cardiology guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios. Each scenario is selectively coded to highlight specific topics therefore, only a subset of the relevant codes are presented. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. #HOSPITAL FOLLOW UP ICD 10 HOW TO#Provider performs screening test and spent 25 minutes for counselingĪ 40 year old female patient present for her HIV test result, doctor advise her that HIV is asymptomatic and spent 35 minutes for counseling.Ĭonclusion: With the above examples we determine how to code the HIV codes when the cases not confirmed, when the patient encounter for HIV testing, when patient with HIV during pregnancy, when HIV patient with unrelated condition.Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection. ICD 10 code for Encounter for screening is Z11.4Ī 32 year old female patient present and request to do HIV test as she had unprotected test. ![]() In this case, the primary diagnosis code will be always O98.7_, followed by HIV(symptomatic-B20 or asymptomatic-Z21) and HIV related condition.Ī pregnant patient in her third trimester at 38 weeks with a symptomatic HIV infection present for check upĪ pregnant patient in her first trimester (8 weeks) diagnoses with HIV, she has not experiencing HIV related condition. Patient with HIV infection during pregnancy, childbirth and the puerperium.Patient admitted with acute appendicitis and positive HIV If the provider document without any symptoms like HIV positive, known HIV or HIV test positive, then we need to assign the Z21 code. The sequencing of code will be in below order.Ī symptomatic HIV patient is at initial visit for sprained left ankleĪ 48 year old female patient with HIV is at the subsequent right hip fractureĪsymptomatic means showing no symptoms. If HIV patient met with an accident and admits the hospital then it’s an unrelated condition, in this case the primary diagnosis code will be unrelated condition, secondary diagnoses code will HIV(B20) and followed by any HIV related condition. HIV Patient admitted for unrelated condition.ICD 10 code for HIV with pnemocytosis is B20, B59Ī patient with AIDS developed Encephalitis as a manifestation of AIDS and is seen in the office for encephalitis The primary ICD 10 code should be HIV B20 and the secondary diagnoses code is HIV related condition. Patient admitted for HIV related condition.Selection and sequencing – ICD 10 code for HIV In the above example we have coded only anemia, as the HIV is not yet confirmed from the physician. ICD 10 code for HIV should be coded only when it’s confirmed from the providerĪssume patient admitted for anemia with possible HIV infection ICD 10 Code for HIV (Human Immunodeficiency Virus) is listed below: ![]()
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