Pathology/Lab Coding Alert

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

Your lab 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.

Use HCPCS Level II for Expanded HIV Screening

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

G0432 -- Infectious agent antibody detection by enzymelinked immunosorbent assay (ELISA) technique antibody, HIV-1 or HIV-2 screening

G0433 -- Infectious agent antibody detection by enzymelinked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-2, screening

G0435 -- Infectious agent detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2 screening.

"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 Virg.

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]."

Verify Coverage by Risk, Pregnancy

Medicare will cover the above HIV screens for two specific types of beneficiaries:

Patients at "increased risk" (see box for risk details) Pregnant women.

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:

1. when the diagnosis of pregnancy is known

2. during the third trimester

3. at labor.

Choose 'V' Code(s) for Medical Necessity

For beneficiaries reporting increased risk factors, use two diagnosis codes on the claim:

• V73.89 -- Special screening for other specified viral disease as primary, and
• V69.8 -- Other problems related to lifestyle as the secondary diagnosis.

For beneficiaries who do not disclose specific increased risk factors, report V73.89 only.

For pregnant Medicare beneficiaries, report V73.89 as primary, and one of the following as secondary (to allow for more frequent screening than the once per 12-month period allows):

• V22.0 -- Supervision of normal first pregnancy
• V22.1 -- Supervision of other normal pregnancy
• V23.9 -- Supervision of unspecified high-risk pregnancy.

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

Await CLFS Payment Rate

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."

Resources: You can find CMS instruction in these matters at: www.cms.gov/MLNMattersArticles/downloads/MM6786.pdf

www.cms.gov/transmittals/downloads/R1935CP.pdf

www.cms.gov/manuals/downloads/ncd103c1_Part4.pdf

http://www.cms.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp (note revised G code definitions July 2010).