Oncology & Hematology Coding Alert

Reserve repeat annual screening only for the high risk patients.

When your physician screens a patient for Hepatitis C, you target code G0472 (Hepatitis C antibody screening, for individual at high risk and other covered indication[s]). Here is a quick review of the provider and place of service requirements to help you bill clean and flawless claims for hepatitis C screening. Also, always check if the patient qualifies for hepatitis C screening. Lastly, you should also be aware of the appropriate diagnosis codes you will report to support medical necessity of 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. So, CMS implemented a new HCPCS code G0472 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

o “CMS considers patients in the last two categories to be at ‘high risk’ for HCV infection,” notes an expert. “Per CMS, the determination of ‘high risk’ for HCV is up to the primary care physician or practitioner who assesses the patient’s history,” he adds.

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. Even patients at high risk due to a history of injected illicit drugs will typically be provided coverage for G0472 only once.

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

Provider and POS requirements: Make sure the documentation you provide reflects a qualified provider performs the screening. The screening and the counseling should be performed by the beneficiary’s primary care physician or practitioner within the context of a primary care setting. CMS verifies the practitioner type by allowing only the following physician specialties supported by the provider’s enrollment record to submit claims for G0472: general practice, family practice, internal medicine, obstetrics/gynecology, pediatric medicine, geriatric medicine.  The following practitioners in primary care may also submit for the service physician assistant, nurse practitioner, certified nurse midwife or certified clinical nurse specialist. 

Also, note CMS limits coverage and payment to certain sites of service for professional fee claims according to the MLN Matters article MM8871. CMS only pays for the service if it is performed and reported 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)
• State or local public health clinic (Place of Service 71)
• 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-10-CM codes to support the necessity of performing the screening for the patient.

When the screening is performed for a patient under high risk initially and the documentation supports it, link G0472 to the ICD-10-CM code Z72.89 (Other problems related to lifestyle). For a repeat of the screening and supporting documentation, report G0472 with the ICD-10-CM codes Z72.89 and 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-10-CM code specific to screening for HCV. You can consider code Z11.59 (Encounter for screening for other viral diseases).

Resources: For more information on screening for HCV, see the MLN Matters 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.