Guidance for Coding HIV Screening – Updates

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Annual HIV screening is a feasible and necessary preventive service, requires claims reimbursement hinges on accurate coding and an explicit knowledge of benefit limitations and requirements.

  • Coding HIV Screening

HIV screening furnished on or after April 13, 2015, on Medicare Part B claims when processed on or after Oct. 2, 2017, are stated with the following HCPCS Level II codes:

HCPCS Code    Descriptor

G0432        –    Infectious agent antibody detection by enzyme Immune assay (EIA) technique, qualitative or Semi-quantitative, multiple-step method, HIV-1 or HIV-2, screening

G0433        –    Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA)      technique, antibody, HIV-1 or HIV- 2, screening

G0435        –    Infectious agent antibody detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening

Necessary HIV primary diagnosis code Z11.4 Encounter for screening for human immunodeficiency virus (HIV) must be followed with a submission of HIV screening HCPCS Level II codes G0475 HIV antigen/antibody, combination assay, screening, G0432, G0433, and G0435.

Submission of CPT 80081 Obstetric panel (includes HIV testing) must also be done with Z11.4 and one of the below secondary diagnosis codes indicating pregnancy:

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, O09.93

  • Claim Line Edits

Claims will get denied by performing a new consistency edit with either the HIV HCPCS Level II codes G0475, G0432, G0433, G0435, or when presented with one of the pregnancies secondary diagnosis codes; however, the Sex Code on the claim shows “Male,” CPT code 80081.

Claims will get denied by performing another new consistency edit for HIV screening code G0475, G0432, G0433, or G0435, coming into effect with dates of service on or after April 13, 2015, if the place of service (POS) is any other than 11 (offices) or 81 (independent labs).

Any claim different than Type of Bill 12X, 13X, 14X, 22X, 23X, and 85X for HIV screening codes G0432, G0433, G0475, and G0435 will also be rejected.

Medicare administrative contractors will calculate the next date the patient is qualified for HIV screening. Screening is covered annually.

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