Wiki HIV Pre-exposure followup

samueltc

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Case 1: Patient came in for HIV pre-exposure follow up visit and was coded with Z20.6 and CPT 99401 with 15 min of counseling, but was rejected by BCBS (Blue Cross Blue Shield)

I have changed the diagnosis to Z11.4, still got rejected by BCBS stating 16-16-LACKS INFO NEEDED FOR ADJUDICATION and M51-M51-INCOMPL/INVALID PX CODES.

Could any one suggest the right diagnosis code???

Case 2: Also, have another scenario wherein patient came in for travel consult, with malaria prophylaxis, and was counseled for 15 minutes.
Dx: Z41.8 was assigned, but got rejected from BCBS (Blue Cross Blue Shield)

Please suggest me the right diagnosis code???
 
Counseling is not screening so a screening Dx code is not appropriate for a CPT code for counseling. If it is pre exposure counseling then it is not correct to code as contact or suspected exposure. you need a counseling dx code if you are going to use a counseling CPT code. I would look under category Z70 for you HIV pre exposure counseling and Z71 for the travel counseling. But then it does depend on if the documentations supports tat was the reason for the counseling. Keep in mind it may not pay due to coverage restrictions.
 
We are a Ryan White funded HIV care clinic and we serve many PrEP patients. We bill 99202-99204, 99212-99214 with modifier 25, and 99401-99404. We use the combination of Z11.3 or Z11.4 with Z20.6 and or Z77.21 as well as Z79.899 if applicable. This always gets paid. We do have a problem with our local BCBS not processing with no out of pocket as is mandated but we are working with them to get this corrected. There are so many ways you can bill these. I have attached a guide for billing PrEP. Hope it helps.
 

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