HIV/AIDS HCC Coding Guide
Complete HCC coding guide for HIV/AIDS (B20) including ICD-10 to HCC mapping, V28 RAF weights, documentation of disease status, and opportunistic infection coding.
Quick Facts
HCC Categories
HCC 1 — HIV/AIDS
RAF Weight Range
0.433
Community, non-dual, aged (V28)
Model
CMS-HCC V28 (PY2026 — 100% phase-in)
6 ICD-10 codes map to payment HCCs
Overview
Human immunodeficiency virus (HIV) infection affects approximately 1.2 million Americans. Under CMS-HCC V28, HIV/AIDS maps to HCC 1 (HIV/AIDS), which carries one of the highest RAF weights in the model. The primary ICD-10-CM code B20 (Human immunodeficiency virus disease) is used for all patients with symptomatic HIV infection. Coding requires documenting the confirmed HIV diagnosis, current antiretroviral therapy, viral load status, CD4 count, and any AIDS-defining conditions or opportunistic infections. The B20 code is used for both symptomatic HIV and AIDS — the ICD-10-CM does not distinguish between the two. Asymptomatic HIV status uses Z21, which does not map to the same HCC category.
ICD-10 to HCC Mapping
| ICD-10 Code | Description | Billable | HCC Mapping |
|---|---|---|---|
| B20 | Human immunodeficiency virus [HIV] disease | Yes | HCC 1 |
| Z21 | Asymptomatic human immunodeficiency virus [HIV] infection status | Yes | No HCC |
| B97.35 | Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere | Yes | No HCC (use with manifestation) |
| Z79.899 | Other long term (current) drug therapy | Yes | No HCC (supporting code for ART) |
| B97.35 | HIV-2 as cause of diseases classified elsewhere | Yes | No HCC (manifestation code) |
| O98.7 | Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium | No | HCC 1 |
| O98.711 | HIV disease complicating pregnancy, first trimester | Yes | HCC 1 |
| O98.712 | HIV disease complicating pregnancy, second trimester | Yes | HCC 1 |
| O98.713 | HIV disease complicating pregnancy, third trimester | Yes | HCC 1 |
| O98.72 | HIV disease complicating childbirth | Yes | HCC 1 |
RAF weights are community, non-dual, aged base coefficients from the CMS-HCC V28 model (PY2026). Verify against the latest CMS rate announcement for payment calculations.
Documentation Tips
Document the confirmed HIV diagnosis — B20 requires a confirmed diagnosis, not just a positive screening test.
Record the most recent CD4 count and viral load to support disease status documentation.
Document current antiretroviral therapy (ART) regimen to satisfy MEAT treatment criteria.
Code any AIDS-defining conditions or opportunistic infections as additional diagnoses when documented.
For patients with undetectable viral loads on ART, B20 remains the appropriate code — do not downgrade to Z21.
Document any HIV-related complications: HIV-associated nephropathy, neurocognitive disorder, wasting syndrome.
Common Coding Mistakes
Coding Z21 (asymptomatic HIV) for patients on antiretroviral therapy — any patient on ART should be coded with B20.
Failing to code AIDS-defining opportunistic infections separately when they are documented (PCP pneumonia, Kaposi sarcoma, etc.).
Not recapturing HIV at annual encounters — B20 must be documented and coded at every encounter for risk adjustment.
Using R75 (inconclusive laboratory evidence of HIV) or Z71.7 (HIV counseling) instead of the confirmed diagnosis code.
V24 to V28 Changes
V28 maintains HIV/AIDS as HCC 1, the same category number as V24 but with recalibrated RAF weights. The RAF weight was adjusted to reflect current treatment costs, which have stabilized due to effective antiretroviral therapy. V28 did not significantly change the HIV/AIDS coding requirements, but the emphasis on accurate documentation of disease status (B20 vs. Z21) remains critical. The hierarchy still places HIV/AIDS at the top of the infectious disease HCC ladder.
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