June 27th is National HIV Testing Day: Coding Fundamentals for HIV Screening

Medicare covers annual HIV screening. It is important for providers to recommend HIV screening because early detection will help their patients live longer, healthier lives. Claims reimbursement for this preventative service is dependent on proper coding and a clear understanding of benefit limitations and requirements. Here’s what you need to know, especially in honor of National HIV testing day, June 27.

HIV Background

HIV is a virus that weakens a person’s immune system by destroying cells that are important in fighting disease and infections. Currently, no effective cure exists for HIV, but timely diagnosis and proper medical care help to control it.

HIV screening involves taking a blood sample and examining it for the presence of HIV antibodies. These disease-fighting proteins react to HIV specifically and when present, indicate active infection. Early treatment, such as antiretroviral therapy, significantly reduces the risk of developing acquired immunodeficiency syndrome (AIDS), the final stage of HIV infection, contracting AIDS-related conditions, and dying of AIDS.

Note: “Increased risk for HIV infection” is defined in the Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 210.7.

Who is Covered?

Medicare covers annual screenings for certain Medicare beneficiaries without regard to perceived risk or who are at increased risk for HIV infection, including anyone who asks for the test, or pregnant women.

Frequency of testing:

• Annually, for Medicare beneficiaries between the ages of 15 and 65 without regard to perceived risk
• Annually, for Medicare beneficiaries younger than 15 and adults older than 65 who are at increased risk for HIV infection
• For Medicare beneficiaries who are pregnant, three times per pregnancy:
  • First, when a woman is diagnosed with pregnancy
  • Second, during the third trimester
  • Third, at labor, if ordered by the woman’s clinician

Coding HIV Screening

HCPCS Level II and CPT Codes

ICD-10-CM Codes

Increased risk factors not reported –  Z11.4

Increased risk factors reported –  Z11.4 & Z72.51, Z72.52, Z72.53, or Z72.89

Pregnant Medicare beneficiaries –  Z11.4 & 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, or O09.93

HIV screening HCPCS Level II codes G0475, G0432, G0433, and G0435 must be submitted with the required HIV primary diagnosis code Z11.4.

Early diagnosis and treatment of HIV can help improve the health of these patients and decrease transmission of the virus. Help spread awareness of the importance of HIV screening as we approach HIV awareness day.

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Stacy Chaplain

Stacy Chaplain, MD, CPC, is an executive editor at AAPC. She has worked in medicine for almost 20 years and has more than 4 years' experience in medical writing & editing. Prior to AAPC, she led a compliance team as Director of Clinical Coding Quality for a multispecialty group practice. Chaplain received her Bachelor of Arts in Biology from The University of Texas at Austin and her Medical Doctorate from The University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Oregon local chapter.

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