Coding HIV Screening for Medicare Beneficiaries
The Centers for Medicare & Medicaid Services (CMS) covers either standard or FDA-approved HIV rapid screening tests, using the following HCPCS G codes:
- G0432 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening
- G0433 Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening
- G0435 Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening
Screenings are covered a maximum of three times per term of pregnancy for pregnant Medicare beneficiaries:
- When the diagnosis of pregnancy is known;
- During the third trimester; and
- At labor, if ordered by the woman’s clinician
HIV screening for pregnant women must be reported with a primary diagnosis code of V73.89 Special screening for other specified viral disease, plus a secondary diagnosis of either V22.0 Supervision of normal first pregnancy, V22.1 Supervision of other normal pregnancy, or V23.9 Supervision of unspecified high-risk pregnancy.
Screenings are covered once per year for beneficiaries at increased risk for HIV infection (11 full months must elapse between tests). Indicate increased risk for HIV on the claim with V73.89 as primary and V69.8 Other problems related to lifestyle as secondary.
For beneficiaries without increased risk factors, report HCPCS Level II code G0432, G0433, or G0435 with diagnosis code V73.89 only. Patients with any known prior diagnosis of HIV-related illness are not eligible for the HIV screening benefit.
The above guidelines apply to all physicians, providers, and clinical diagnostic laboratories submitting claims to Medicare contractors (Fiscal Intermediaries (FI), carriers, and Parts A/B Medicare administrative contractors (A/B MACs)) for services to Medicare beneficiaries.
You can find complete instructions in MLN Matters® Number: MM6786 Revised.
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