Medicare Compliance & Reimbursement

Don't miss out on rapid test pay for high-risk beneficiaries.

You can now show medical necessity for a greater number of human immunodeficiency virus (HIV) screening tests -- but you'll need to learn the diagnosis and procedure coding ins and outs if you want to reap the rewards.

CMS announced an HIV screening coverage expansion and created three new "G" codes to implement the coverage. Read on for your need-to-know briefing, including which diagnoses payers will recognize and how to get paid for the service for encounters retroactive to Dec. 8, 2009.

To report HIV screenings for certain beneficiaries, turn to one of the following new codes:

"It looks like this change is primarily authorizing rapid tests" for individuals at "increased risk" of contracting HIV, comments Jean S. Oglevee, LPN, CPC, director of coding, compliance and clinical services at Family Medicine Clifton/ Centreville in Virginia.

Early warning: "The HIV antigen can be detected early in the course of HIV, before the appearance of antibodies," notes Jill Young, CPC, CEDC, CIMC, with Young Medical Consulting LLC in East Lansing, Mich. "This test has a specific 'early window' -- some resources say 16 days [after exposure]."

Frequency: Beneficiaries at increased risk may receive "one annual voluntary HIV screening." Pregnant women, however, may receive three voluntary HIV screenings for each term of pregnancy:

Note: Patients with any known prior diagnosis of HIV-related illness are not eligible for this screening test.

Per Medicare instruction, your lab may have been using unlisted code 87999 (Unlisted microbiology procedure) for the HIV screen. Contractors established pricing for that service, and will likely continue to price the G codes the same way until they appear on the Clinical Lab Fee Schedule (CLFS) Jan. 1, 2011.

Downside: When Medicare "suggests" an unlisted code, this is not a guarantee of payment, warns Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CCC, CEMC, CMC, healthcare coding consultant and CEO/President of Terry Fletcher Consulting, Inc. in Laguna Beach, Calif. Rather, the unlisted code gives "the provider an option to capture the service and hope for reimbursement."

Editor's note: You can find CMS instruction in these matters at: http://www.cms.gov/MLNMattersArticles/downloads/MM6786.pdf; http://www.cms.gov/transmittals/downloads/R1935CP.pdf; http://www.cms.gov/manuals/downloads/ncd103c1_Part4.pdf; and http://www.cms.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp (note revised G code definitions July 2010).