New Medicare Benefit: HPV Screening

New Medicare Benefit: HPV Screening

The Centers for Medicare & Medicaid Services (CMS) has added Human Papillomavirus (HPV) testing to the list of Medicare covered preventive services, under specific conditions.

Conditions for Coverage

CMS will cover screening for cervical cancer with HPV testing once every 5 years as a preventive service benefit under Medicare for asymptotic patients age 30 to 65 years old, with a Pap smear.

Coding Claims

CMS has created a new code to report this service: Effective July 9, 2015, labs (place of service 81 Independent laboratory or 11 Office) may report HCPCS Level II G0476 HPV combo assay, CA screen.

This code will be priced by Medicare administrative contractors for claims with dates of service between July 9, 2015 to December 31, 2016. Beginning January 1, 2017, G0476 will be priced and paid according to the Clinical Laboratory Fee Schedule. As cervical cancer screening is a preventive service, no coinsurance or deductible applies.

To support medical necessity of G0476, appropriate diagnosis coding is:

For dates of service before October 1, 2015 – ICD-9 V73.81 Special screening examination for human papillomavirus (HPV) [as primary] and V72.31 Routine gynecological examination [as secondary]

For dates of service on or after October 1, 2015 – ICD-10 Z11.51 Encounter for screening for human papillomavirus (HPV) and Z01.411 Encounter for gynecological examination (general)(routine) with abnormal findings or Z01.419 Encounter for gynecological examination (general)(routine) without abnormal findings

Refer to national coverage determination 210.2.1 for complete guidance.

Source: MLN Matters 9434

Renee Dustman

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.
Renee Dustman

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Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

3 Responses to “New Medicare Benefit: HPV Screening”

  1. Thelma Stewart says:

    I appreciate the updates. Thanks!

  2. Linda says:

    Baby Boomers are a new breed of seniors. We are socially and sexually active and mentally alert as a group, generally. We need to provide the HPV test and vaccine for women over 65. While there isn’t sufficient studies about this, we should err on the side of safety and offer it to women through age 75. We pay our premiums and must have a say as to how the dollars are spent. Perhaps if you stop paying for various arm, knee, hand, back and other unproven mostly nonfunctional items, money could be spent more wisely. Thank you for your consideration of these matters.

  3. Emily says:

    Speaking from experience, be aware that if Clinical Labs sends the HPV test to a different lab location than the Pap smear, and if each location bills Medicare separately for each test , Medicare will pay for the Pap smear but may deny the HPV test as “routine” and not covered. If this occurs, you will have to file an appeal with Medicare, informing them that the HPV test was done in conjunction with the Pap smear as a preventative procedure and not routine (providing you were 65 at the time and had not been tested for HPV in the last 5 years). This happened to me today and Medicare confirmed that HPV is covered but due to the way it was billed, it was denied and I will have to file an appeal.

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