Knowledge Base Article

As discussed in Transmittal 1935 and Transmittal 118, effective for dates of service on and after December 8, 2009, CMS will cover both standard and FDA-approved HIV rapid screening tests as described below.  The implementation date of these transmittals is July 6, 2010.

Coverage Requirements

1. A maximum of one, annual voluntary HIV screening of Medicare beneficiaries at increased risk for HIV infection per USPSTF guidelines as follows: 

•  Men who have had sex with men after 1975
• Men and women having unprotected sex with multiple [more than one] partners
• 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 being treated for sexually transmitted diseases
• Persons with a history of blood transfusion between 1978 and 1985
• Persons who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals not willing to disclose high-risk behaviors; and,

2. A maximum of three, voluntary HIV screenings of pregnant Medicare beneficiaries: (1) when the diagnosis of pregnancy is known, (2) during the third trimester, and (3) at labor, if ordered by the woman’s clinician.

Procedure Codes

The following HCPCS codes are to be billed for HIV screening:

• G0432- Infectious agent antigen detection by enzyme immunoassay (EIA) technique, qualitative or semi-quantitative, multiple-step method, HIV-1 or HIV-2, screening,
• G0433 - Infectious agent antigen detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-2, screening, and,
• G0435 - Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening.

Diagnosis Coding

Claims for HIV screening shall be submitted with one or more of the following diagnosis codes:

a. For claims where increased risk factors are reported: V73.89 as primary and V69.8 as secondary.
b. For claims where increased risk factors are NOT reported: V73.89 as primary only.
c. For claims for pregnant Medicare beneficiaries, the following diagnosis codes shall be submitted in addition to V73.89 to allow for more frequent screening than once per 12-month period:
 V22.0 – Supervision of normal first pregnancy, or,
 V22.1 – Supervision of other normal pregnancy, or,
 V23.9 - Supervision of unspecified high-risk pregnancy.

Other Information

Applicable Bill Types are 12X, 13X, 14X, 22X, 23X, and 85X. Use revenue code 030X (laboratory, clinical diagnostic).

HIV testing for diagnostic purposes continues to be covered under Section 190.14 of the National Coverage Determination manual.  The coverage indications for diagnostic HIV testing and a list of covered diagnosis codes can be found in the NCD Coding Policy Manual for Laboratory Services (see pages 52-59).

For more information, refer to MLN Matters Article MM6786.