Coverage Update for Hepatitis C Virus Screening

Coverage Update for Hepatitis C Virus Screening

The Centers for Medicare & Medicaid Services (CMS) recently announced Medicare coverage for screening of the hepatitis C virus (HCV), in accordance with recommendations by the United States Preventive Services Task Force (USPSTF).

Effective June 2, 2014 CMS will cover screening for HCV with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory tests. Tests are covered when ordered by the beneficiary’s primary care physician or practitioner in a primary care setting.

Who’s Eligible?

Tests must be performed by an eligible Medicare provider for adult beneficiaries who meet one of the following risk categories:

  1. High risk for HCV infection, which is defined as persons with a current or past history of illicit injection drug use and persons who have a history of receiving a blood transfusion prior to 1992. Annual screening is covered for persons who have had continued illicit injection drug use since the prior negative screening test.
  2. Does not meet the “high risk” definition above, but was born 1945-1965; a single, once-in-a-lifetime screening test is covered.

The determination of “high risk for HCV” is identified by the primary care physician or practitioner who assesses the patient’s history, which is part of any complete medical history, typically part of an annual wellness visit, and considered in the development of a comprehensive prevention plan. The medical record should reflect the service provided.

Claims Processing Requirements

For Medicare claims with dates of service on or after June 2, 2014 report HCPCS Level II code G0472 Hepatitis C antibody screening for individual at high risk and other covered indication(s). This code won’t appear in the Clinical Laboratory Fee Schedule and Integrated Outpatient Code Editor until January 2016; however, Medicare administrative contractors will apply contractor pricing to claims with dates of service June 2, 2014 through December 31, 2015 that are brought to their attention.

For patients who are at high risk initially (regardless of age), report ICD-9 code V69.8 Other problems related to lifestyle (ICD-10 code Z72.89). For illicit injection drug users, also report ICD-9 diagnosis code 304.91 Unspecified drug dependence, continuous (ICD-10 code F19.20 Other psychoactive substance abuse, uncomplicated).

As with all preventive services, beneficiary coinsurance and deductible do not apply to G0472.

Source: MLN Matters® article MM8871

Renee Dustman

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print production and content management, and has worked in a variety of capacities for several publications.
Renee Dustman

About Has 533 Posts

Renee Dustman, BS, MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print production and content management, and has worked in a variety of capacities for several publications.

3 Responses to “Coverage Update for Hepatitis C Virus Screening”

  1. Elisabeth says:

    For “baby boomers” born 1945-1965 how do not have Z7289 or F1920 as diagnosis do we use Z11.59 as diagnosis for G0472 Hep C antibody screening?

  2. Holly Brosz says:

    Renee – I am wondering if you could contact me regarding the hepatitis C screening. One of the rheumatologists at our clinic does quite a bit of these. We have our patients sign an ABN form, however, some choose not to have the test done because there is the possibility their insurance won’t cover the test.

    Thank you!
    Holly

  3. TATIANA says:

    What is the Medicare reimbursement mount. I am having a hard time finding this. Thank you.

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