Part B Insider (Multispecialty) Coding Alert

Reader Questions:

Learn HIV Risk Factors

Question: I understand that Medicare has an expanded HIV screening policy for patients in a high risk group. What factors make a patient "high risk" under Medicare's rule?

Answer: The HIV high risk group is eligible for one annual voluntary HIV screening. Medicare defines "high risk" as anyone with one of the following characteristics:

Men who have had sex with men after 1975

Men and women having unprotected sex with multiple [more than one] partners

Past or present injection drug users

Men and women who exchange sex for money or drugs,or have sex partners who do

Individuals whose past or present sex partners were HIVinfected, bisexual, or injection drug users

Persons being treated for sexually transmitted diseases

Persons with a history of blood transfusion between 1978 and 1985

Persons who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals not willing to disclose high-risk behaviors.

Note that Medicare's expanded HIV screening coverage also extends to pregnant women at the following three times:

when the diagnosis of pregnancy is known

during the third trimester

at labor.

Source: CMS's Decision Memo on HIV screening, available at http://www.cms.gov/transmittals/downloads/R1935CP.pdf.

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