Wiki G0475 -- dx code needed

[NIKI01]

Good afternoon,
I have a quick question regarding the additional dx for G0475 test on 71y/o patient. Billing processed the claim with Z11.4 (screening for HIV).
Z11.4 was the only dx listed on the requisition for the blood work and there was no provider's documentation linked to the requisition. However, the claim was rejected based on dx. The billing department is looking for secondary diagnosis codes denoting high risk factors. In my opinion there should be only Z11.4 coded because lack of provider's documentation; however, the billing dept. sent it back to me to review this account again. How be this account coded?
Please advise.

thank you so much

 

[CBLENNIE]

Did you review the Medicare NCD 210.7 Screening for the Human Immunodeficiency Virus (HIV) infection (linked here)? The coverage guidelines indicate that for members over 65 years of age, they must be at increased risk of an HIV infection, and it defines what it means to be at an increased risk for HIV infection?


If you are just billing with DX Z11.4, there is nothing that indicates the patient is at an increased risk of infection and since they are over 65 it is not covered by Medicare. Per 100-4 Medicare Claims Processing Chapter 18 Preventive Screening Services section 130 HIV Screening Tests in 130.5 Diagnosis Code Reporting item a. lists the DX codes that indicate there is an increased risk.

 

[NIKI01]

Thank you so much for the information. It is very hard to code from the requestion where is no additional dx listed. The patient is 71 y/o and it is at an increased risk for infection. However, I cannot guess if Z72.89, Z72.51, Z72.52, or Z 72.53 should be used without the supporting documentation on the requestion.
Thank you so much again,

 

[CBLENNIE]

Thank you so much for the information. It is very hard to code from the requestion where is no additional dx listed. The patient is 71 y/o and it is at an increased risk for infection. However, I cannot guess if Z72.89, Z72.51, Z72.52, or Z 72.53 should be used without the supporting documentation on the requestion.
Thank you so much again,

You're more than welcome.