Pathology/Lab Coding Alert

HCPCS Level II:

G0472 to the Rescue for Hepatitis C Screening

Published on Thu Jun 11, 2015

Don’t report additional lab test code.

When your lab performs a test for Hepatitis C virus (HCV), you’re used to selecting the appropriate CPT® code for your work based on the lab method.

But a CMS decision to cover screening tests for HCV means that there’s a different code you need to know: G0472 (Hepatitis c antibody screening, for individual at high risk and other covered indication[s]).

Let our experts tell you when and how you should report G0472 instead of another CPT® code for the test. That way you won’t miss out on HCV test pay for Medicare beneficiaries covered under the screening rule.

Choose CPT® for Non-Medicare or Diagnostic Tests

If your lab performs a test for HCV for a non-Medicare patient, you’ll have to rely on CPT® codes to report your work. Even if the physician orders an HCV test for a Medicare patient based on symptoms that indicate possible HCV infection, you’ll still need to turn to one of the following codes, based on the lab method you use:

86803 — Hepatitis C antibody A positive antibody test indicates a likely past or current HCV infection, but requires subsequent confirmatory testing.

86804 — … confirmatory test (e.g., immunoblot) Report this code for a confirmatory test following a positive 86803 test

87520 — Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique Persistence of HCV RNA more than six months beyond initial infection indicates chronic disease.

87521 — … hepatitis C, amplified probe technique, includes reverse transcription when performed Positive results on this test, possibly accompanied by elevated blood levels of alanine aminotransferase (ALT), indicate active infection.

87522 — … hepatitis C, quantification, includes reverse transcription when performed Physicians order this test to monitor treatment of patients with confirmed HCV infection.

87902 — Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus Physicians may order this test for cases of confirmed HCV infection, because genotype impacts possible treatment regimens.

Use G0472 for Medicare HCV Screening

CMS added HCV screening coverage for adults in January of this year, but the policy actually has an effective date for services beginning June 2, 2014. Before that time, Medicare generally didn’t cover screening HCV testing.

Do this: Regardless of the lab test method, report an HCV screening for a Medicare beneficiary using G0472. This code won’t appear in the Clinical Laboratory Fee Schedule and Integrated Outpatient Code Editor until January 2016; however, Medicare administrative contractors will apply contractor pricing to claims with dates of service June 2, 2014 through December 31, 2015 that are brought to their attention.

The lab test must be an “FDA approved/cleared laboratory test (used consistently with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations),” according to CMS instruction. That includes point-of-care tests such as rapid antibody tests.

Caution: Don’t additionally report a CPT® code if the lab performs the test under the Medicare screening policy.

“CMS will cover the HCV screening with an appropriate FDA-approved lab test … 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 for these service,” said Nathan L. Kennedy, Jr., CPC, CHC, CPPM, CPC-I during an NGS Medicare online conference.

Know who’s eligible: Medicare will provide the HCV screening 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 with a current or past history of illicit injection drug use.

“CMS considers patients in the last two categories to be at ‘high risk’ for HCV infection,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians (AAFP) in Kansas City, Mo. “Per CMS, the determination of ‘high risk’ for HCV is up to the primary care physician or practitioner who assesses the patient’s history,” adds Moore.

As with all preventive services, beneficiary coinsurance and deductible do not apply to G0472.

Beware frequency: For patients born between the years 1945-1965, CMS will provide coverage for HCV screening only once in their lifetime. Also, the agency provides HCV screening coverage is only once for patients who have had blood transfusions prior to the year 1992.

“Medicare will provide coverage for G0472 for all patients, including even those at high risk due to a history of injected illicit drugs, only once,” adds Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel.

Repeat test exception: CMS covers repeat HCV screening only for patients who have had continued illicit injection drug use since the prior negative screening test. The agency provides for annual screening as long as the patient continues to meet the criteria of continued illicit injection drug use. CMS defines “annual” as “11 full months must pass following the month of the last negative HCV screening.”

POS requirements: CMS limits coverage and payment for HCV screening to certain sites of service. According to the MLNMatters article MM8871, CMS pays only for HCV screening performed in one of the following places of service (POS):