New Guidance for Coding HIV Screening
Annual HIV screening is a reasonable and necessary preventive service, but claims reimbursement hinges on correct coding and a clear understanding of benefit limitations and requirements.
Coding HIV Screening
HIV screening furnished on or after April 13, 2015, on Medicare Part B claims processed on or after Oct. 2, 2017, are reported with the following HCPCS Level II codes:
|G0432||Infectious agent antibody detection by enzyme Immune assay (EIA) technique, qualitative or Semi-quantitative, multiple-step method, HIV-1 or HIV-2, screening|
|G0433||Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV- 2, screening|
|G0435||Infectious agent antibody detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening.|
HIV screening HCPCS Level II codes G0475 HIV antigen/antibody, combination assay, screening, G0432, G0433, and G0435 must be submitted with the required HIV primary diagnosis code Z11.4 Encounter for screening for human immunodeficiency virus (HIV).
CPT 80081 Obstetric panel (includes HIV testing) must also be submitted with Z11.4 and one of the following secondary diagnosis codes denoting pregnancy:
- Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34,90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, O09.93
Claim Line Edits
A new consistency edit will deny claims with either the HIV HCPCS Level II codes G0475, G0432, G0433, G0435, or CPT code 80081 when submitted with one of the pregnancy secondary diagnosis codes, but the Sex Code on the claim indicates “Male.”
Another new consistency edit will deny any claims for HIV screening code G0475, G0432, G0433, or G0435, effective with dates of service on or after April 13, 2015, if the place of service (POS) is anything other than 11 (office) or 81 (independent lab).
Any claim other than Type of Bill 12X, 13X, 14X, 22X, 23X, and 85X for HIV screening codes G0475, G0432, G0433, and G0435 will also be denied.
Medicare administrative contractors will calculate the next date the patient is eligible for HIV screening. Screening is generally covered annually.
Source: MLN Matters Article MM9980, May 24, 2017
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