Human Immunodeficiency Virus (HIV) Screening

HCPCS/CPT Codes

  • 80081 - Obstetric panel (includes HIV testing)
  • G0432 - Infectious agent antibody detection by enzyme immunoassay (EIA) technique
  • G0433 - Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique
  • G0435 - Infectious agent antibody detection by rapid antibody test
  • G0475 - HIV antigen/antibody, combination assay, screening

Frequency

  • Annually for beneficiaries between 15 - 65 years without regard to perceived risk
  • Annually for beneficiaries under 15 years and adults older than 65 who are at increased risk for HIV infection:
    • Men who have sex with men
    • Men and women having unprotected vaginal or anal intercourse
    • Past of 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 HIV-infected, bisexual, or injection drug users,
    • Persons who have acquired or request testing for other sexually transmitted infectious diseases,
    • Persons with a history of blood transfusions between 1978 and 1985,
    • Persons who request an HIV test despite reporting no individual risk factors,
    • Persons with new sexual partners,
    • Persons who, based on individualized physician interview and examination
  • Pregnant beneficiaries covered three times during pregnancy
    • When diagnosed as pregnant
    • During third trimester
    • At labor, if ordered by clinician

Diagnosis Code

Increased risk factors not reported

  • Z11.4 - Encounter for screening for human immunodeficiency virus

Increased risk factors reported

  • Z11.4 - Encounter for screening for human immunodeficiency virus; and
  • Z72.89 - Other problems related to lifestyle
  • Z72.51 - High risk heterosexual behavior
  • Z72.52 - High risk homosexual behavior; or
  • Z72.53 - High risk bisexual behavior

Pregnant Medicare beneficiaries

  • Z11.4 - Encounter for screening for human immunodeficiency virus; and
  • Z34.00 - Encounter for supervision of normal first pregnancy, unspecified trimester
  • Z34.01 - Encounter for supervision of normal first pregnancy, first trimester
  • Z34.02 - Encounter for supervision of normal first pregnancy, second trimester
  • Z34.03 - Encounter for supervision of normal first pregnancy, third trimester
  • Z34.80 - Encounter for supervision of other normal pregnancy, unspecified trimester
  • Z34.81 - Encounter for supervision of other normal pregnancy, first trimester
  • Z34.82 - Encounter for supervision of other normal pregnancy, second trimester
  • Z34.83 - Encounter for supervision of other normal pregnancy, third trimester
  • Z34.90 - Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
  • Z34.91 - Encounter for supervision of normal pregnancy, unspecified, first trimester
  • Z34.92 - Encounter for supervision of normal pregnancy, unspecified, second trimester
  • Z34.93 - Encounter for supervision of normal pregnancy, unspecified, third trimester
  • O09.90 - Supervision of high risk pregnancy, unspecified, unspecified trimester
  • O09.91 - Supervision of high risk pregnancy, unspecified, first trimester
  • O09.92 - Supervision of high risk pregnancy, unspecified, second trimester; or
  • O09.93 - Supervision of high risk pregnancy, unspecified, third trimester

Coverage

Beneficiaries must meet one of the following:

  • Beneficiaries at increased risk for HIV infection
  • Anyone who asks for test
  • Pregnant women

Noncoverage

  • Beneficiary with any known diagnosis of HIV-related illness
  • Beneficiary who has had screening within one year
  • Pregnant beneficiary who has had three specified screening tests within each respective term of pregnancy

Payment

Copayment/coinsurance waived; Deductible waived

Noridian Medicare Portal

Yes - G0475

Resources

Last Updated Mar 20 , 2024