Oncology & Hematology Coding Alert

Question: Our physician includes HIV screening for patients reporting for treatment as well as for those in follow up and preventive care. Can we code for HIV screening services?

New Mexico Subscriber

Answer: When your physician orders screening of a patient for HIV infection, you will need to be aware of the new HCPCS code that has been introduced by CMS for this service. Effective with dates of service on or after April 13, 2015, CMS introduced a new HCPCS code, G0475 (HIV antigen/antibody, combination assay, screening) you can report for HIV screening services provided to a patient.

Observe coverage criteria for G0475: CMS covers the screening with the appropriate FDA approved lab tests and point of care tests when it’s ordered by the beneficiary’s physician or practitioner within the context of a healthcare setting and performed by an eligible Medicare provider.

You can report G0475 for patients who undergo HIV screening and who meet the specifications detailed below:

Patients aged between 15 to 65 years irrespective of their risk status of HIV infection

Patients younger than 15 years or older than 65 years who are at increased risk of HIV infection.

Know other coverage guidelines for G0475: As mentioned above, CMS will provide coverage for screening of HIV infection that has to be reported using the HCPCS code, G0475. For individuals aged between 15 to 65 years and for individuals aged below 15 years or older than 65 years who are at increased risk of HIV infection, CMS will provide coverage for a maximum of one annual voluntary screening.

For any additional claims: If claims exceed the maximum number of screenings that are allowed per year, then the claim will be denied.