Wiki preventive medicine codes vs preventive counseling codes for HIV PrEP

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Troykall1

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We are a Community Based Organization with a small LGBTQIA+ clinic. In addition to our care for those living with HIV, we see many patients who are on or would like to be on PrEP (pre exposure prophylactic's). We have been coding the established PrEP visits with CPT 99396 or 99395 and diagnosis Z20.6. Colorado Anthem BCBS keeps applying a copay to these visits. We also have issues when the patient requests care beyond the PrEP, currently we will bill with E/M but nothing for the PrEP in these cases. Can we bill an E/M with modifier 25 and then also bill cpt 99401-99404? Should we not be billing 99396, 99395 at all? Thank you.
 
Troykall1 said:
We are a Community Based Organization with a small LGBTQIA+ clinic. In addition to our care for those living with HIV, we see many patients who are on or would like to be on PrEP (pre exposure prophylactic's). We have been coding the established PrEP visits with CPT 99396 or 99395 and diagnosis Z20.6. Colorado Anthem BCBS keeps applying a copay to these visits. We also have issues when the patient requests care beyond the PrEP, currently we will bill with E/M but nothing for the PrEP in these cases. Can we bill an E/M with modifier 25 and then also bill cpt 99401-99404? Should we not be billing 99396, 99395 at all? Thank you.
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PrEP and the associated clinic visits do fall under the ACA preventive healthcare benefits. If the patient is on an ACA compliant plan and you are an in-network provider, there shouldn't be a copay.

My first question is: Are you an in-network provider with Colorado Anthem BCBS at that specific location? If not, that explains why there is a copay. If you are in-network and the patient does have an ACA plan, then I would guess that Anthem doesn't like the way you're billing the claim. I will have to do some additional research on how they might want the claims coded and billed - if I find anything, I will come back and post it.

ACA preventive benefit mandate info:


Additional info specific to PrEP coverage under ACA:


Is PrEP Covered By My Insurance?​

In most cases, yes! Under the Affordable Care Act, PrEP must be free under almost all health insurance plans. That means you can’t be charged for your PrEP medication or the clinic visits and lab tests you need to maintain your prescription. There are no out-of-pocket costs for you.

This applies to most private health insurance plans you get through your employer or purchase yourself, individual plans you purchase through HealthCare.gov or state-based Marketplaces, and state Medicaid expansion coverage plans. In some states, the traditional Medicaid program also covers PrEP at no charge.https://www.hiv.gov/hiv-basics/hiv-...to-reduce-risk/pre-exposure-prophylaxis#_edn1 This does not automatically apply to Medicare. (Medicare Part D prescription drug plans cover PrEP medication, but there will still be cost sharing.)
 
I think I might see a potential problem...perhaps Anthem doesn't like your diagnosis code and is not considering Z20.6 a screening/preventive diagnosis code. Anthem may be processing the claim under a treatment benefit based on contact/exposure rather than under the prevention benefit. (If it's not that, I'm stumped. Unless you're not an Anthem network provider or the patient is not on an ACA compliant plan.)

Here's a link to a Colorado Anthem Provider Update - I'm also posting a paragraph from the link below:


Beginning July 1, 2020, most of Anthem Blue Cross and Blue Shield (Anthem)’s ACA compliant non-grandfathered health plans will cover pre-exposure prophylaxis (PrEP) medication at 100% with no member cost share, when used for prevention of HIV and dispensed at an in-network pharmacy with a prescription.

Since medications used for PrEP can also be used to treat HIV, Anthem will review medical and pharmacy claims data to determine if a member has been diagnosed and prescribed treatment for HIV or prescribed PrEP for preventive purposes. When prescribed for prevention of HIV, this drug is covered with no member cost share. When prescribed for treatment of HIV, member cost shares apply based on the member’s benefit plan.
 
Thanks everyone. We are in network with BCBS Anthem. I have not had a claim that I appealed that doesn’t get rerun as prevention. I’ve had a few United healthcare (we are in network) self insured groups that are not ACA but when I appeal them they also cover as prevention. I am having to appeal a lot. I will try a different diagnosis code. I was using z20.6 as this is the code that CDPHE told us to use for their PrEP assistance program PHIP. It sounds like that was their choice and not the standard. I really appreciate all the advice.
 
lgardner said:
I am curious why you are coding preventive visits for these patients.

it seems like regular E/Ms would be more appropriate.
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When we opened the clinic four years ago we met with the Colorado department of public health and environment and this was the advice they gave us. ACA also states PrEP is covered under prevention. We are also funded by Ryan White so we are bound by many rules CDPHE lays out. I am beginning to see their advice may not apply to all insurances. Always learning.
 
Hi Troy K:)
I d bill Eval/Mgmnt CPT codes then add modifier 25 with CPT 99401 behavior counseling(ensure provider add 5-10 minutes in documentation discussing STD (sex transmitted disease) and protection Etc). I would not use preventive CPT visit unless annual wellness physical given. If the patient is being seen for chronic condition monitoring or specific illness then add that info too then discussion on STD cautions. I d use dx Z01.89 or Z11.3 or Z11.4 instead of Z20.6 but it all depends on provider s documentation. Z01.89 is first listed dx code too. Are you using a unspecific dx code first (A63.8) then Z code last? However if positive lab results show specific STD such as B20, A56, A52, A54 I'd link that first on the claim....and influence of documentation too.
Well I hope I helped or gave you some more insight.
Lady T 😉
 
Last edited:
TThivierge said:
Hi Troy K:)
I d bill Eval/Mgmnt CPT codes then add modifier 25 with CPT 99401 behavior counseling(ensure provider add 5-10 minutes in documentation discussing STD (sex transmitted disease) and protection Etc). I would not use preventive CPT visit unless annual wellness physical given. If the patient is being seen for chronic condition monitoring or specific illness then add that info too then discussion on STD cautions. I d use dx Z01.89 or Z11.3 or Z11.4 instead of Z20.6 but it all depends on provider s documentation. Z01.89 is first listed dx code too. Are you using a unspecific dx code first (A63.8) then Z code last? However if positive lab results show specific STD such as B20, A56, A52, A54 I'd link that first on the claim....and influence of documentation too.
Well I hope I helped or gave you some more insight.
Lady T 😉
Click to expand...
Does the insurances apply a copay and or coinsurance/Deductible when you bill E/M with Modifier 25 + 99401? the main issue we are having is that patients understand that PrEP should be covered at 100%. Out of pockets have been charged on our claims as well as the LabCorp bill. When I appeal the prevention codes with notes they always get reprocessed, I also have to send the notes to LabCorp so their claims get covered. This all takes place regardless if we use IDC10 z01.89 z11.3 a11.4 or z20.6. thank for the help.
 
sls314 said:
I think I might see a potential problem...perhaps Anthem doesn't like your diagnosis code and is not considering Z20.6 a screening/preventive diagnosis code. Anthem may be processing the claim under a treatment benefit based on contact/exposure rather than under the prevention benefit. (If it's not that, I'm stumped. Unless you're not an Anthem network provider or the patient is not on an ACA compliant plan.)

Here's a link to a Colorado Anthem Provider Update - I'm also posting a paragraph from the link below:


Beginning July 1, 2020, most of Anthem Blue Cross and Blue Shield (Anthem)’s ACA compliant non-grandfathered health plans will cover pre-exposure prophylaxis (PrEP) medication at 100% with no member cost share, when used for prevention of HIV and dispensed at an in-network pharmacy with a prescription.

Since medications used for PrEP can also be used to treat HIV, Anthem will review medical and pharmacy claims data to determine if a member has been diagnosed and prescribed treatment for HIV or prescribed PrEP for preventive purposes. When prescribed for prevention of HIV, this drug is covered with no member cost share. When prescribed for treatment of HIV, member cost shares apply based on the member’s benefit plan.
Click to expand...
Thank you for all of this. Anthem did send me a copy of this and stated that the best way to ensure coverage is to appeal the claim when a copay etc. is applied. I am seeing from all the advise that this may be a diagnosis code issue and not a CPT issue. Thanks again.
 
sls314 said:
PrEP and the associated clinic visits do fall under the ACA preventive healthcare benefits. If the patient is on an ACA compliant plan and you are an in-network provider, there shouldn't be a copay.

My first question is: Are you an in-network provider with Colorado Anthem BCBS at that specific location? If not, that explains why there is a copay. If you are in-network and the patient does have an ACA plan, then I would guess that Anthem doesn't like the way you're billing the claim. I will have to do some additional research on how they might want the claims coded and billed - if I find anything, I will come back and post it.

ACA preventive benefit mandate info:


Additional info specific to PrEP coverage under ACA:


Is PrEP Covered By My Insurance?​

In most cases, yes! Under the Affordable Care Act, PrEP must be free under almost all health insurance plans. That means you can’t be charged for your PrEP medication or the clinic visits and lab tests you need to maintain your prescription. There are no out-of-pocket costs for you.

This applies to most private health insurance plans you get through your employer or purchase yourself, individual plans you purchase through HealthCare.gov or state-based Marketplaces, and state Medicaid expansion coverage plans. In some states, the traditional Medicaid program also covers PrEP at no charge.https://www.hiv.gov/hiv-basics/hiv-...to-reduce-risk/pre-exposure-prophylaxis#_edn1 This does not automatically apply to Medicare. (Medicare Part D prescription drug plans cover PrEP medication, but there will still be cost sharing.)
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Thank you for looking into this. I felt like I had it right because all other payers are covering the visits as prevention, then in July we started getting all the Anthem claims back with copays and patients were so surprised. Any help is appreciated.
 
Hi Troykall,
I just want you to know sometimes the insurance payers will change the insurance rules on provider and subscribers. Plus payers have own do's and don't s when the insurance algorithms kicks in. Also keep in mind the patient's medical treatment for the year are being monitored along with their deductibles along with copayments. In this economy of high inflation many changes going on in differ types of business. Appealing claims takes time and the payers can hold on to money that way while you appealing denied claims.. As a past reimbursement manager, you always do everything in compliance with the provider's documentation plus he or she shows the medical necessity treatment provided while abiding by the payer rules in how to bill it. It can be tricky. The lab CPT codes do have edits built in most computerized Encoder system. However if provider is ordering labs; he or she should give you a definitive dx code to assist in reason for the lab test not just Z dx code all the time. most payers go by the CMS website physician fee and the NCCI website. This list all CPT codes with coordinating dx codes for coverage which most payers follow.
Well I hope I helped you a bit
Lady T
 
Hi everyone, thank you for all this information. I am going to contact all our contracted payers and ask that they provide guidance on how they would like us to bill for the PrEP visits. our health Access department has also sent the Anthem letter regarding grandfathered policies to the state for clarification.
 
Hi everyone, I was able to get an awesome guide to PrEP billing from the HIV Medicine Association. I realize now it is all in the Diagnosis code that the payors use to determine it is a PrEP visit. I will be following my claims closely to see if this solves the Aetna and Anthem Problem. I have shared the guide here. Thank you all for all the advice.
 

Attachments

  • prep-april-2018-1 guide.pdf
    679.3 KB · Views: 30
Troykall1 said:
Hi everyone, I was able to get an awesome guide to PrEP billing from the HIV Medicine Association. I realize now it is all in the Diagnosis code that the payors use to determine it is a PrEP visit. I will be following my claims closely to see if this solves the Aetna and Anthem Problem. I have shared the guide here. Thank you all for all the advice.
Click to expand...
Even more news! I met with Gilead today and they said that we can now amend any E/M code with a modifier 33 to indicate that the services are A or B rated and should be processed with no copay or deductible. I also checked the forum under Modifier 33 and the information there supports the use of modifier 33. I am so glad to have access to these forums. thanks again for all the advice. This modifier is only for commercial plans. It is not valid with Medicare or Medicaid.
 
Troykall1 said:
Even more news! I met with Gilead today and they said that we can now amend any E/M code with a modifier 33 to indicate that the services are A or B rated and should be processed with no copay or deductible. I also checked the forum under Modifier 33 and the information there supports the use of modifier 33. I am so glad to have access to these forums. thanks again for all the advice. This modifier is only for commercial plans. It is not valid with Medicare or Medicaid.
Click to expand...
Hi Troy,

Can you please share more details on the billing codes example you used to get paid without any patient cost sharing for PrEP visits? We are PCP office in Florida and commercial insurances are still applying copays and deductibles towards PrEP visits. Are you using Z29.81 code as Primary when billing? I truly appreciate your help.

Example :

99214-33 Modifier (Z29.81, Z72.52, Z20.6) Dx pointers 1,2,3?
 
mimraapc said:
Hi Troy,

Can you please share more details on the billing codes example you used to get paid without any patient cost sharing for PrEP visits? We are PCP office in Florida and commercial insurances are still applying copays and deductibles towards PrEP visits. Are you using Z29.81 code as Primary when billing? I truly appreciate your help.

Example :

99214-33 Modifier (Z29.81, Z72.52, Z20.6) Dx pointers 1,2,3?
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There have been big changes since the adoption of ICD 10 Z29.81. I have had claims from Cigna and Anthem BCBS deny now to modifier 33 misuse. Our claims have been paying now with no cost share when using Z29.81 without modifier 33, for all payers but Cigna open access. Open access is falling back on the Texas law suite that has pushed back on PrEP coverage. https://ysph.yale.edu/news-article/...re-than-2000-hiv-infections-in-the-next-year/ . your best bet is if they apply a cost share to appeal with notes and a message about paying according to Bill HR3815 116th congress. I wish I had better news but this is what is working for me right now.
 
Troykall1 said:
There have been big changes since the adoption of ICD 10 Z29.81. I have had claims from Cigna and Anthem BCBS deny now to modifier 33 misuse. Our claims have been paying now with no cost share when using Z29.81 without modifier 33, for all payers but Cigna open access. Open access is falling back on the Texas law suite that has pushed back on PrEP coverage. https://ysph.yale.edu/news-article/...re-than-2000-hiv-infections-in-the-next-year/ . your best bet is if they apply a cost share to appeal with notes and a message about paying according to Bill HR3815 116th congress. I wish I had better news but this is what is working for me right now.
Click to expand...
Thank you for your response. We are PCP provider in South Florida and all of our private payers (BCBS, Cigna, Aetna, UHC, Humana etc) are not paying for PrEP visits without patient coast sharing. They are applying patient copay's, deductibles and co-insurances. Can you please help me and provide some coding example to see how your claims are successfully paid? Are you billing the visit with just Z29.81 as a primary and only ICD-10 on the charge page with E/M code (99212-99215)? I am sharing some of my examples below how we billed it out. I truly appreciate your help.

99214-95 Modifier (Telehealth) (ICD = Z29.81, Z72.52) Dx pointers 1,2
99214-25 Modifier + 36415 (ICD = Z29.81, Z72.52)Dx pointers 1,2
99214 - 25 Modifier + (ICD = Z29.81, Z72.52)Dx pointers 1,2 - 90677 + 90471 (ICD = Z23 ) Dx Pointer 3
99214 -95 Modifier (Telehealth) (ICD = Z29.81, E78.2, E29.1, D75.1, I10, Z72.52) Dx pointers 1
99214 (ICD = Z29.81, Z72.52) Dx pointers 1
 
Mimraapc
Why are you using those Z dx codes first? Insurance companies do not like them as first dx codes; they are not first listed Z dx codes. Also these Z dx codes CANNOT be primary dx codes..ICD10 manual states this rule. Use the patient s diagnosis problem area documented then Z dx codes last. I d put the dx I10 or D75.1 or E29.1 first per doctor s assessments given from documentation. Your modifiers look fine. Ahh do these male patients have any problems documented related to dx blocks of N40 to N53,B20,N25-N39 R10.2 R35, R37 or R39, R32, or R30? Dx codes of A56 or A54.2 should be lab supported positive results.
I hope helped you a little bit
Lady T
 
TThivierge said:
Mimraapc
Why are you using those Z dx codes first? Insurance companies do not like them as first dx codes; they are not first listed Z dx codes. Also these Z dx codes CANNOT be primary dx codes..ICD10 manual states this rule. Use the patient s diagnosis problem area documented then Z dx codes last. I d put the dx I10 or D75.1 or E29.1 first per doctor s assessments given from documentation. Your modifiers look fine. Ahh do these male patients have any problems documented related to dx blocks of N40 to N53,B20,N25-N39 R10.2 R35, R37 or R39, R32, or R30? Dx codes of A56 or A54.2 should be lab supported positive results.
I hope helped you a little bit
Lady T
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There is no alternative then to bill the Z29.81 because they are being seen only for PrEP for HIV. There are guidelines set up for this special billing. For more information I have attached a good presentation on billing for HIV for PrEP and injectable PrEP. I know that in general the coding rules are that Z codes are to support a primary DX but in this case there is no primary DX. We are trying to prevent a primary diagnosis of B20 (HIV) I hope this helps some.
 

Attachments

  • PDF-Webinar-Slides-PrEP-Billing-Coding_0.pdf
    1.4 MB · Views: 5
mimraapc said:
Thank you for your response. We are PCP provider in South Florida and all of our private payers (BCBS, Cigna, Aetna, UHC, Humana etc) are not paying for PrEP visits without patient coast sharing. They are applying patient copay's, deductibles and co-insurances. Can you please help me and provide some coding example to see how your claims are successfully paid? Are you billing the visit with just Z29.81 as a primary and only ICD-10 on the charge page with E/M code (99212-99215)? I am sharing some of my examples below how we billed it out. I truly appreciate your help.

99214-95 Modifier (Telehealth) (ICD = Z29.81, Z72.52) Dx pointers 1,2
99214-25 Modifier + 36415 (ICD = Z29.81, Z72.52)Dx pointers 1,2
99214 - 25 Modifier + (ICD = Z29.81, Z72.52)Dx pointers 1,2 - 90677 + 90471 (ICD = Z23 ) Dx Pointer 3
99214 -95 Modifier (Telehealth) (ICD = Z29.81, E78.2, E29.1, D75.1, I10, Z72.52) Dx pointers 1
99214 (ICD = Z29.81, Z72.52) Dx pointers 1
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Your coding is spot on. If BCBS of Florida is like Athem in Colorado they will deny the 36415 we bundled even with the 25. It is such a sore spot here. Also, does Florida have a PrEP assistance program? We have PHIP here in Colorado that is based on federal poverty level that will pay for cost share if the insurance wont. We have all our PrEP patients sign up during intake. https://cdphe.colorado.gov/public-health-intervention-program I would check with your department for public health. This may be a good solution for you. Our department of public health also provides Bicillin for Syphilis for free for the uninsured. We just send in a form and a currier brings us the drugs. I hope this helps.
 

Attachments

  • PDF-Webinar-Slides-PrEP-Billing-Coding_0.pdf
    1.4 MB · Views: 4
TThivierge said:
Mimraapc
Why are you using those Z dx codes first? Insurance companies do not like them as first dx codes; they are not first listed Z dx codes. Also these Z dx codes CANNOT be primary dx codes..ICD10 manual states this rule. Use the patient s diagnosis problem area documented then Z dx codes last. I d put the dx I10 or D75.1 or E29.1 first per doctor s assessments given from documentation. Your modifiers look fine. Ahh do these male patients have any problems documented related to dx blocks of N40 to N53,B20,N25-N39 R10.2 R35, R37 or R39, R32, or R30? Dx codes of A56 or A54.2 should be lab supported positive results.
I hope helped you a little bit
Lady T
Click to expand...
Hello, I tried billing them as primary but then insurances still consider the visit problematic and apply the copay.
 
Troykall1 said:
There is no alternative then to bill the Z29.81 because they are being seen only for PrEP for HIV. There are guidelines set up for this special billing. For more information I have attached a good presentation on billing for HIV for PrEP and injectable PrEP. I know that in general the coding rules are that Z codes are to support a primary DX but in this case there is no primary DX. We are trying to prevent a primary diagnosis of B20 (HIV) I hope this helps some.
Click to expand...
Thank you so much. I had watched NASTED entire webinar when they released it on PrEP billing/Coding and followed their guidelines but still insurances are not accepting it in the state of Florida. I appreciate your help.
 
Troykall1 said:
Your coding is spot on. If BCBS of Florida is like Athem in Colorado they will deny the 36415 we bundled even with the 25. It is such a sore spot here. Also, does Florida have a PrEP assistance program? We have PHIP here in Colorado that is based on federal poverty level that will pay for cost share if the insurance wont. We have all our PrEP patients sign up during intake. https://cdphe.colorado.gov/public-health-intervention-program I would check with your department for public health. This may be a good solution for you. Our department of public health also provides Bicillin for Syphilis for free for the uninsured. We just send in a form and a currier brings us the drugs. I hope this helps.
Click to expand...
We have some PrEP assistance programs here like Viiv and BRHPC. I work them with closely. Appreciate your help.
 
Our company does PrEP visits for the prevention of HIV in Florida. We have begun using the new dx code Z29.81, but are receiving denials from Aetna and Ambetter when using this code as primary code. I know some insurances do not like a Z code as a primary code, but this is a unique situation because the patient is asymptomatic, and we are trying to prevent the patient from having an HIV dx. Does anyone know or have had experience with this issue and a possible solution? TIA for any input.
 
jlblair71465 said:
Our company does PrEP visits for the prevention of HIV in Florida. We have begun using the new dx code Z29.81, but are receiving denials from Aetna and Ambetter when using this code as primary code. I know some insurances do not like a Z code as a primary code, but this is a unique situation because the patient is asymptomatic, and we are trying to prevent the patient from having an HIV dx. Does anyone know or have had experience with this issue and a possible solution? TIA for any input.
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We don't work with Ambetter but I have never had a problem with Aetna and z29.81for PrEP. Are they denying for invalid DX? ViiV is really great at assisting with billing problems.
This is the ViiV account manager contact info here in Colorado they should be able to get you your rep info. They are really helpful. You can tell them I gave you their info. Troy Kall from Colorado Health Network.
Hyosun Kinnar
720-205-8279
hyosun.x.kinnear@viivhealthcare.com
 
Troykall1 said:
We don't work with Ambetter but I have never had a problem with Aetna and z29.81for PrEP. Are they denying for invalid DX? ViiV is really great at assisting with billing problems.
This is the ViiV account manager contact info here in Colorado they should be able to get you your rep info. They are really helpful. You can tell them I gave you their info. Troy Kall from Colorado Health Network.
Hyosun Kinnar
720-205-8279
hyosun.x.kinnear@viivhealthcare.com
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We normally bill and e/m code (ex 99213) and the consult code 99401. Which line do you put the dx code Z29.81 on? Our denials are mostly that the dx codes are all "Z" codes and they cannot process the claim. Are you billing just the E/M code? I have researched and it is not clear what CPT code you bill the Z29.81 with.
 
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