2025 ICD-10-CM code Z21
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status and contact with health services - Persons with potential health hazards related to communicable diseases Factors influencing health status and contact with health services (Z00-Z99) Feed
Asymptomatic human immunodeficiency virus [HIV] infection status.This code indicates an encounter for an asymptomatic HIV-positive individual.
Modifiers may apply depending on the specific services provided during the encounter.Consult current coding guidelines for appropriate modifier usage.
Medical necessity is established by the need for ongoing monitoring of an asymptomatic HIV-positive individual to prevent disease progression, detect early signs of opportunistic infections, and optimize adherence to ART regimens to maintain viral suppression.Regular monitoring and timely intervention are crucial for improving long-term health outcomes.
The clinical responsibility involves monitoring the patient's HIV status, providing counseling regarding disease management, and ordering/interpreting tests to assess viral load and CD4+ cell count.Additional responsibilities may include prescribing and monitoring antiretroviral therapy (ART).
- Factors influencing health status and contact with health services (Z00-Z99)
- Z20-Z29 (Persons with potential health hazards related to communicable diseases)
In simple words: This code is used when someone has HIV but isn't currently sick.It's used to record a visit to the doctor related to managing their HIV status, like a check-up or test.
Asymptomatic human immunodeficiency virus (HIV) infection status. This ICD-10-CM code is used to classify encounters for individuals who are HIV-positive but are currently asymptomatic.It is crucial to note that a corresponding procedure code must be included if a procedure is performed during the encounter. This code should not be used for individuals with acquired immunodeficiency syndrome (AIDS) or those with conclusive evidence of HIV disease.It is also distinct from codes representing contact with or exposure to HIV.
Example 1: A 35-year-old male presents for a routine HIV checkup, including CD4 count, viral load testing, and counseling on medication adherence.He is asymptomatic., A 28-year-old female, diagnosed with HIV three years ago, presents for a follow-up appointment with her infectious disease specialist.She is asymptomatic and requires a prescription refill for her ART regimen.Her viral load is undetectable., A 40-year-old male, recently diagnosed with HIV through routine screening, presents for his initial post-diagnosis consultation and counseling session with a physician or qualified healthcare professional. He's asymptomatic, but needs to discuss treatment options and risk reduction strategies.
Documentation should include the patient's HIV positive status confirmed by laboratory testing, current symptoms (or lack thereof), date of diagnosis, details on current medication and adherence, CD4 count, viral load, and any other relevant lab results.Counseling notes should be documented.If any procedures were performed, these must also be documented with corresponding procedure codes.
** When coding for HIV-related services, always consider the specific services rendered and ensure appropriate codes are utilized for both diagnosis and procedures.Refer to the latest ICD-10-CM guidelines for detailed instructions and potential updates.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Infectious Disease, Internal Medicine, Family Medicine
- Place of Service:Office, Outpatient Hospital, Clinic