Screening for the Human Immunodeficiency Virus (HIV) Infection

Date Issued: 4/26/2016

Effective for claims with dates of service on or after April 13, 2015, new HCPCS code G0475 (HIV antigen/antibody, combination assay, screening) will be recognized as a new covered service for HIV screening.

The Centers for Medicare & Medicaid Services (CMS) Change Request (CR) 9403 instructs that effective for claims with dates of service on and after April 13, 2015, CMS will cover screening for HIV with the appropriate U.S. Food and Drug Administration (FDA)-approved laboratory tests and point-of-care tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations, when ordered by the beneficiary’s physician or practitioner within the context of a healthcare setting and performed by an eligible Medicare provider for these services, for beneficiaries who meet one of the following conditions below:

1) Except for pregnant Medicare beneficiaries addressed below, a maximum of one, annual, voluntary screening for all adolescents and adults between the ages of 15 and 65, without regard to perceived risk.

  • Claims with HCPCS Code G0475 for beneficiaries between the ages of 15 and 65 without regard to risk must also be submitted with a primary diagnosis code of either V73.89 (ICD-9) or Z11.4 (ICD-10)

2) Except for pregnant Medicare beneficiaries addressed below, a maximum of one, annual, voluntary screening for adolescents younger than 15 and adults older than 65 who are at increased risk for HIV infection. Increased risk for HIV infection is defined as follows:

  • Men who have sex with men;
  • Men and women having unprotected vaginal or anal intercourse;
  • Past or present injection drug users;
  • Men and women who exchange sex for money or drugs, or have sex partners who do;
  • Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users;
  • Persons who have acquired or request testing for other sexually transmitted infectious diseases;
  • Persons with a history of blood transfusions between 1978 and 1985;
  • Persons who request an HIV test despite reporting no individual risk factors;
  • Persons with new sexual partners; or
  • Persons who, based on individualized physician interview and examination, are deemed to be at increased risk for HIV infection. The determination of “increased risk” for HIV infection is identified by the health care practitioner who assesses the patient’s history, which is part of any complete medical history, typically part of an annual wellness visit and considered in the development of a comprehensive prevention plan. The medical recommendation should be a reflection of the service provided.
    • Claims with HCPCS Code G0475 for beneficiaries less than age 15 or greater than age 65 with increased risk must also be submitted with a primary diagnosis code of either V73.89 (ICD-9) or Z11.4 (ICD-10) and a secondary diagnosis code that denotes the high risk. The ICD-9 secondary codes are V69.2 or V69.8. The ICD-10 secondary diagnosis codes are Z72.51, Z72.89, Z72.52, or Z72.53. If that secondary code is not present, the line item will be denied

3. A maximum of three voluntary HIV screenings of pregnant Medicare beneficiaries:

  • When the diagnosis of pregnancy is known;
  • During the third trimester; and
  • At labor, if ordered by the woman’s clinician

Effective for claims with dates of service on or after April 13, 2015, EmblemHealth will deny line-items on claims for pregnant beneficiaries denoted by a secondary diagnosis code above denoting pregnancy, if HCPCS Code G0475, HIV screening, or CPT code 80081, obstetric panel, and primary diagnosis code V73.89/ Z11.4, as appropriate, are not present on the claim.

On professional claims, the place of service must be either 81 (independent laboratory) or 11 (office).

If claims are received for screenings that exceed the maximum number allowed per year, the claim line item will be denied.