Pathology/Lab Coding Alert

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?

Illinois Subscriber

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