Find comprehensive information on HIV screening, including clinical documentation, medical coding (ICD-10 Z11.4, SNOMED CT 73898005), healthcare guidelines, and testing procedures. Learn about HIV diagnosis, prevention, risk factors, and available resources for patients and healthcare professionals. Explore accurate and up-to-date information on HIV antibody testing, viral load testing, and early detection strategies. This resource supports proper healthcare documentation and facilitates informed decision-making regarding HIV testing and patient care.
Also known as
Encounter for HIV screening
Routine HIV screening or testing.
Human immunodeficiency virus [HIV] status
Follow-up care related to confirmed HIV status.
Abnormal immunological findings
May be used if screening reveals immunological abnormalities.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the encounter for HIV screening?
Yes
Is the patient at high risk for HIV?
No
Do not code HIV screening. Code for the reason of encounter.
When to use each related code
| Description |
|---|
| HIV Screening |
| Acute HIV Infection |
| HIV-1 Infection |
Q: What are the most recent CDC recommendations for HIV screening in primary care settings, including frequency and patient populations?
A: The CDC recommends routine HIV screening for all individuals aged 13-64 in all healthcare settings, including primary care. For patients at increased risk of HIV (e.g., men who have sex with men, people who inject drugs, transgender women), more frequent screening, at least annually, is recommended. Pregnant women should be screened at their first prenatal visit and again in the third trimester if at continued risk. Opt-out screening, where patients are notified they will be screened unless they decline, is the preferred approach. Explore how these guidelines can be implemented within your specific practice to ensure comprehensive patient care. Consider implementing a standardized HIV screening protocol to streamline the process.
Q: How can I differentiate between false positive HIV antibody tests and actual HIV infection in my clinical practice, and what are the confirmatory testing algorithms to use?
A: False positive HIV antibody tests can occur due to a variety of factors, including certain autoimmune conditions, pregnancy, or recent vaccinations. Differentiating a false positive from a true positive requires confirmatory testing. If an initial antibody test is reactive, the next step is typically a HIV-1/HIV-2 antibody differentiation immunoassay. If this test is positive for HIV-1 antibodies, it is considered a confirmed positive. If the differentiation assay is indeterminate or negative, a nucleic acid test (NAT) is recommended to definitively determine HIV status. Learn more about the latest algorithms and best practices for confirming HIV diagnosis to ensure accurate patient management.
Patient presents for HIV screening. Risk factors assessed include sexual history, intravenous drug use, and previous blood transfusions. Patient reports (insert patient-reported risk factors or denial of risk factors). Physical examination unremarkable. HIV screening test ordered: (specify test type e.g., fourth-generation HIV-1/2 antigenantibody immunoassay, rapid antibody test). Pre-test counseling provided, including discussion of HIV transmission, testing methodology, and potential outcomes. Patient demonstrated understanding of the testing process and provided informed consent. Results pending. Plan to contact patient with results and provide post-test counseling as appropriate. If positive, further testing, including HIV RNA viral load and CD4 count, will be ordered. Referral to infectious disease specialist and initiation of antiretroviral therapy will be considered based on test results. ICD-10 code Z11.4 assigned for encounter for screening for human immunodeficiency virus. CPT codes (insert appropriate CPT codes for testing and counseling) billed. Patient returns for HIV screening results. The (specify test type e.g., fourth-generation HIV-1/2 antigenantibody immunoassay) returned (positive or negative). Post-test counseling provided, including interpretation of results and discussion of next steps. For a positive result, patient was informed about the significance of the positive screening test and the need for confirmatory testing. HIV RNA viral load and CD4 count ordered. Referral to infectious disease specialist made. Discussion regarding antiretroviral therapy initiated. Importance of adherence and follow-up emphasized. For a negative result, patient counseled on risk reduction strategies and the importance of repeat testing based on individual risk assessment. Information regarding HIV prevention methods, including pre-exposure prophylaxis (PrEP), provided. Patient education materials distributed. ICD-10 code (Z11.4 for negative screen, B20 for confirmed HIV) assigned. CPT codes (insert appropriate CPT codes for testing and counseling) billed.