A confirmed HIV positive patient who presents to the clinic for a medication refill for a condition not related to his HIV. The ICD-10-CM codes reported are the Z76.0 Z21.
Per ICD-10-CM guidelines I.C.1.a.2.d, Z21 Asymptomatic human immunode±ciency virus (HIV) infection, is to be applied when the patient without any documentation of symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” or similar terminology. In the ICD-10-CM Alphabetic Index, look for HIV/positive, seropositive guiding you to code Z21. For medication re±ll look in the Alphabetic Index for Issue of/repeat prescription (appliance) (glasses) (medicinal substance, medicament, medicine) Z76.0. The main reason for the visit is a medication refill.