Health Information Management

Membership Update: HIV documentation tip in honor of World AIDS Day

CDI Strategies, December 4, 2014

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Monday, December 1, was World AIDS Day—a day when various social, governmental, and healthcare agencies join forces to raise awareness about disease treatment and prevention and to remember those who have succumbed to the deadly virus. This year’s theme was “Focus, Partner, Achieve: An AIDS-free Generation.” For many CDI specialists, marking the event represents a somber occasion. Those who have not felt the disease’s touch within their personal circles nevertheless have a significant role to play in ensuring that accurate documentation for the disease and its related conditions gets appropriately captured.

In her book, The CDI Specialist’s Complete Training Guide, Laurie L. Prescott writes that

“CDI specialists need to clarify any medical record documentation as to whether the reason for admission is an HIV-related condition or not. Coders cannot assume the relationship just because an HIV-related condition is diagnosed and the patient has HIV disease. If the record does not explicitly state that the condition leading to admission is an HIV-related condition, a query is needed to clarify.”

CDI specialists need to review the chapter-specific guidelines for Infectious and Parasitic Diseases within the Official ICD- 9-CM Guidelines for Coding and Reporting and within the Official ICD-10-CM Guidelines for Coding and Reporting (draft) to identify the similarities and any changes to the code set guidelines, Prescott suggests.

In honor of World AIDS Day, ACDIS posted this sample HIV query to its social media accounts, taken from the Forms & Tools Library. Follow us on social media for this and other interesting information on:

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