Human Immunodeficiency Virus (HIV) Screening and Pre-exposure

CMS has determined that Pre-Exposure Prophylaxis (PrEP) using antiretroviral drugs to prevent Human Immunodeficiency Virus (HIV) is covered as an additional preventive service as recommended with a grade of A by the United States Preventive Services Task Force (USPSTF). CMS determined that PrEP using antiretroviral drugs to prevent HIV is reasonable and necessary for the prevention of an illness or disability and is appropriate for individuals entitled to Medicare benefits under Part A or enrolled under Part B.

PrEP Antiretroviral Drugs to Prevent HIV - Transition from Part D to Part B (October 1, 2024)

  • CMS encourages pharmacies and other affected parties to transition their coverage, from Medicare Part D to Medicare Part B, for PrEP antiretroviral drugs to prevent HIV
    • Includes supplying or dispensing and administration of injectable PrEP
  • The following billable to A/B MAC and not DME MAC:
    1. Up to eight individual counseling visits every 12 months
      • Includes HIV risk assessment (initial or continued), HIV risk reduction, and medication adherence
      • Counseling may be furnished by physician, qualified healthcare practitioner (QHP), or clinical staff
      • Individuals must be competent and alert at time counseling provided
      • G0011: Individual counseling for pre-exposure prophylaxis (PrEP) by physician or QHP to prevent human immunodeficiency virus (HIV), includes HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence, 15-30 minutes,
      • G0013: Individual counseling for pre-exposure prophylaxis (PrEP) by clinical staff to prevent human immunodeficiency virus (HIV), includes HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence
    2. Up to eight HIV screening tests every 12 months
    3. Single screening for hepatitis B virus (HBV)
  • HCPCS billed to A/B MAC:
    • Drug codes: J0739, J0750, J0751, J0799
      • Priced by invoice effective September 30 - December 31, 2024
      • Physician or practitioner buys injectable PrEP drug - submit to A/B MAC
      • Part B pharmacy supplier, submit to A/B MAC
      • DMEPOS supplier, submit to DME MAC
    • Injection of PrEP for HIV prevention: G0012
    • Pharmacy Fees: Q0516, Q0517, Q0518, Q0519, and Q0520
  • ICD-10 diagnosis codes
    • Z29.81 - Encounter for HIV pre-exposure prophylaxis
    • Z11.4 - Encounter for screening for HIV
    • Increased risk factors - refer to CMS PrEP link under Resources

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 Oct 04 , 2024