HIV/AIDS HCC Coding Guide
HIV/AIDS (e.g. B20) maps to HCC 1 (HIV/AIDS) under the CMS-HCC V28 risk adjustment model, with a community, non-dual, aged RAF weight of 0.301; V28 reached 100% phase-in for payment year 2026. Z79.899, other long term (current) drug therapy, is non-HCC under V28.
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.
Medically reviewed by Jess P., CPC · Reviewed: May 9, 2026 · Updated for CMS-HCC V28 and FY2026 ICD-10-CM
Quick Facts
HCC Categories
HCC 1, HIV/AIDS
RAF Weight Range
0.301
Community, non-dual, aged (V28)
Model
CMS-HCC V28 (PY2026, 100% phase-in)
4 ICD-10 codes map to payment HCCs
What HCC category does HIV/AIDS map to under V28?
Human immunodeficiency virus (HIV) infection affects roughly 1.2 million Americans, and most carry it as a chronic, treated condition. Under CMS-HCC V28, HIV/AIDS maps to HCC 1 (HIV/AIDS), which carries one of the highest single-code RAF weights in the model at 0.301 for the community non-dual aged population. The primary ICD-10-CM code B20 (Human immunodeficiency virus disease) is reported for patients with confirmed HIV disease, and it covers both symptomatic HIV and AIDS, since ICD-10-CM does not split the two. To support the diagnosis, document the confirmed HIV status, current antiretroviral therapy, viral load, CD4 count, and any AIDS-defining or opportunistic conditions. Note that asymptomatic status code Z21 also maps to HCC 1 in V28, so both routes risk-adjust to the same 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 | HCC 1 |
| B97.35 | Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere | Yes | HCC 1 |
| Z79.899 | Other long term (current) drug therapy | Yes | No HCC (not risk-adjusting under V28) |
| B97.35 | HIV-2 as cause of diseases classified elsewhere | Yes | HCC 1 |
| O98.7 | Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium | No | No HCC (not risk-adjusting under V28) |
| O98.711 | HIV disease complicating pregnancy, first trimester | Yes | No HCC (not risk-adjusting under V28) |
| O98.712 | HIV disease complicating pregnancy, second trimester | Yes | No HCC (not risk-adjusting under V28) |
| O98.713 | HIV disease complicating pregnancy, third trimester | Yes | No HCC (not risk-adjusting under V28) |
| O98.72 | HIV disease complicating childbirth | Yes | No HCC (not risk-adjusting under V28) |
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.
HCC Buddy maps HIV/AIDS from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
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 keeps HIV/AIDS in a single category, HCC 1, carrying it forward from the prior V24 model while recalibrating the RAF weight to 0.301 for the community non-dual aged factor. That weight reflects current treatment costs, which have stabilized thanks to effective antiretroviral therapy. The coding requirements did not change much, so accurate, recaptured documentation each year remains the priority. One point worth flagging: unlike many conditions whose codes fan out to a primary category plus separate manifestation HCCs, the core HIV codes (B20 and Z21) both land on HCC 1, with no additional disease-specific HCC stacked on top. Any opportunistic infections are still coded separately on their own merits.
Related Conditions
Related references
Sources
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.
Verified current to CMS-HCC V28, payment year 2026 — last reviewed May 9, 2026.
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