Gastroenterology Coding Alert

Repeated screening is no longer taboo for high-risk patients.

You’ll find your pay success for Hep C screenings will improve if you’ve got the latest information on the eligible conditions for coverage, provider and POS requirements, and the appropriate diagnosis codes to support medical necessity for this service.

Background: Prior to June 2, 2014, CMS did not provide any coverage for screening of HCV in adults. Pursuant to §1861(ddd) of the Social Security Act, CMS may add coverage of “additional preventive services” through the National Coverage Determination (NCD) process. CMS then reviewed the necessity of adding coverage for screening of HCV in adults. Based on the review, CMS implemented a new HCPCS code (G0472, Hepatitis C antibody screening, for individual at high risk and other covered indication[s]) in January 2015, although the agency actually made this effective for dates of service starting June 2, 2014.

Observe Coverage Criteria For HCV Screening

CMS will now cover the screening with the appropriate FDA approved lab tests and point of care tests when it’s ordered by the beneficiary’s primary care physician or practitioner within the context of a primary care setting and performed by an eligible Medicare provider.

The HCV screening is provided to patients who fall under one of the following categories:

• Patients who were born between the years 1945 to 1965
• Patients who have had a blood transfusion prior to the year 1992
• Patients who with a current or past history of illicit injection drug use
• CMS considers patients in the last two categories to be at ‘high risk’ for HCV infection. Per CMS, the determination of ‘high risk’ for HCV is up to the primary care physician or practitioner who assesses the patient’s history.

Know the Coverage Guidelines For G0472

For patients born between the years 1945-1965, CMS will provide coverage for HCV screening only once in their lifetime. Also, coverage is provided only once for patients who have had blood transfusions prior to the year 1992. “Medicare will provide coverage for G0472 for all patients, including even those at high risk due to a history of injected illicit drugs, only once,” adds Michael Weinstein, MD, Vice President of Capital Digestive Care.

Repeat screening: CMS will cover repeat screenings for high-risk persons annually only for persons who have had continued illicit injection drug use since the prior negative screening test. “Annual” is defined by CMS as “11 full months must pass following the month of the last negative HCV screening.”

Provider and POS requirements: Make sure that the documentation that you provide reflects information that a qualified provider performs the screening. The screening and the counseling should be performed by the beneficiary’s primary care physician (which CMS defines as general practice, family practice, internal medicine, obstetrics/gynecology, pediatric medicine, or geriatric medicine) or by the beneficiary’s physician assistant, nurse practitioner, certified nurse midwife, or certified clinical nurse specialist.

Also, note that CMS limits coverage and payment to certain sites of service. According to the MLNMatters article MM8871, CMS only pays for the service if it is performed in one of the following places of service:

• Physician’s Office (Place of Service 11)
• Outpatient Hospital (Place of Service 22)
• Independent Clinic (Place of Service 49)
• Federally Qualified Health Centers (Place of Service 50)
• State or local public health clinic (Place of Service 71)
• Rural Health Clinic (Place of Service 72)
• Independent Laboratory (Place of Service 81)

Include Appropriate Diagnosis Codes to Support Medical Necessity

When your provider performs HCV screening for a patient, you will have to include the appropriate ICD-9 (or ICD-10 codes, when it becomes effective) codes to support the necessity of performing the screening for the patient.

When the screening is performed for a patient under high risk initially, you will have to link G0472 to the ICD-9 code, V69.8 (Other problems related to lifestyle). This ICD-9 code crosswalks to Z72.89 (Other problems related to lifestyle) in ICD-10. For a repeat of the screening, you will have to report G0472 with the ICD-9 codes, V69.8 and 304.91 (Unspecified drug dependence, continuous use). Under ICD-10, this will change to F19.20 (Other psychoactive substance dependence, uncomplicated).

CMS does not appear to specify a diagnosis code to link to G0472 for individuals who are not at high risk, and there is no ICD-9 code specific to screening for HCV. One suggestion would be to use V73.89 (Special screening examination for viral and chlamydial diseases; Other specified viral diseases) under ICD-9 and Z11.59 (Encounter for screening for other viral diseases) under ICD-10.

Resources: For more information on screening for HCV, see the MLMatters article at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8871.pdf or the transmittal about this topic at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R177NCD.pdf.