Preventive Services List: A-H

Medicare covers the following preventive services and screenings, subject to certain eligibility and other limitations.

 

Alcohol Misuse Screening and Counseling

Category Coverage and Benefit Resources
HCPCS/CPT Codes
  • G0442 - Annual alcohol misuse screening, 15 minutes
  • G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
Frequency
  • G0442 - Annually
  • G0443 - For those who screen positive, four times per year
Coverage

Screening: All Medicare beneficiaries are eligible

Counseling: Beneficiaries who screen positive are eligible if:

  • They are competent and alert at the time counseling is provided; and
  • Counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting
Counseling Requirements

Counseling is to be completed based on Five As Approach

  1. Assess: Ask about or assess behavioral health risks and factors affecting choice of behavior change goals/methods.
  2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient's interest in and willingness to change the behavior.
  4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
  5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0442 and G0443

 

Annual Wellness Visit (AWV)

Category Coverage and Benefit Resources
HCPCS/CPT Codes
  • G0438 - Initial visit
  • G0439 - Subsequent visit
Frequency
  • G0438 - Once in a lifetime
  • G0439 - Annually
Coverage
  • Beneficiary not within 12 months after effective date of their first Medicare Part B coverage period
  • Has not received Initial Preventive Physical Examination (IPPE) or AWV within past 12 months
  • Performed by health professional:
    • Physician
    • Physician assistant
    • Nurse practitioner
    • Clinical nurse specialist
    • Medical professional (including health educator, registered dietitian, nutrition professional or other licensed practitioner) or team of such medical professionals, working under direct supervision of physician
No specific diagnosis code required; bill using the most appropriate diagnosis
Payment

Copayment/coinsurance waived; Deductible waived

Resources
Noridian Medicare Portal Yes - G0438 and G0439

 

Bone Mass Measurements

Category Coverage and Benefit Resources
HCPCS/CPT Codes
  • 76977 - Ultrasound bone density measurement and interpretation, peripheral site(s), any method
  • 77078 - Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
  • 77080 - Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
  • 77081 - DXA, bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
  • 77085 - DXA, bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment
  • G0130 - Single energy X-ray absorptiometry (SEXA) bone density study, one or more sites, appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
Frequency Every two years; more frequently if medically necessary
Coverage

Beneficiary must fall into one of the following categories:

  • Women determined by physician or qualified non-physician practitioner to be estrogen deficient and at clinical risk for osteoporosis
  • Individuals with vertebral abnormalities
  • Individuals getting (or expecting to get) glucocorticoid therapy for more than three months
  • Individuals with primary hyperparathyroidism
  • Individuals being monitored to assess response to U.S. Food and Drug Administration (FDA)-approved osteoporosis drug therapy
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Cardiovascular Disease Screening Tests

Category Coverage and Benefit Resources
HCPCS/CPT Codes
  • 80061 - Lipid panel, this panel must include:
    • 82465 - Cholesterol, serum, total
    • 83718 - Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
    • 84478 - Triglycerides
Frequency Once every five years
Diagnosis Code

Z13.6 - Encounter for screening for cardiovascular disorders

Coverage All Medicare beneficiaries without apparent signs or symptoms of cardiovascular disease
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - 80061, 82465, 83718 and 84478

 

Cervical Cancer Screening with Human Papillomavirus (HPV) Tests

Category Coverage and Benefit Resources
HCPCS/CPT Codes

G0476 - Cervical cancer screening, all-inclusive HPV co-test with cytology (Pap smear)

Frequency Once every five years
Diagnosis Code
  • Z11.51 - Encounter for screening for human papillomavirus; and
    • Z01.411 - Encounter for gynecological examination (general) (routine) with abnormal findings; or
    • Z01.419 - Encounter for gynecological examination (general) (routine) without abnormal findings
Coverage
  • Female beneficiaries aged 30 - 65 years
  • Asymptomatic
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Colorectal Cancer Screening

Category Coverage and Benefit Resources
Fecal Occult Blood Test

CPT and HCPCS:

  • 82270 - Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (e.g., patient was provided three cards or single triple card for consecutive collection)
  • G0328 - Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous

Frequency: Once every 12 months

82270 may be billed in place of G0328; however, both cannot be performed in same 12-month period

Coverage:

  • Aged 45 and older at normal risk for developing colorectal cancer; or
  • At high risk for developing colorectal cancer

Payment: Copayment/coinsurance waived; Deductible waived

Cologuard Multitarget Stool DNA

CPT: 81528 - Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result

Frequency: Once every three years

Diagnosis:

  • Z12.11 - Encounter for screening for malignant neoplasm of colon; and
  • Z12.12 - Encounter for screening for malignant neoplasm of rectum

Coverage:

  • Aged 45 and older
  • Asymptomatic
  • At average risk of developing colorectal cancer

Payment: Copayment/coinsurance waived; Deductible waived

Complete Colorectal Cancer Screening

Screening colonoscopy following a positive result from non-invasive stool-based CRC screening test

  • A complete colorectal cancer screening is a flexibility that allows a colonoscopy that follows a positive result from a non-invasive stool-based CRC screening test to be billed as a screening procedure, not diagnostic.
  • Apply -KX modifier to the claim for the screening colonoscopy to identify the complete colorectal cancer screening context.
Flexible Sigmoidoscopy

HCPCS: G0104 - Flexible Sigmoidoscopy

Frequency:

  • High risk: Once every 48 months
  • Not high risk: Once every 48 months (unless beneficiary does not meet criteria for high risk of developing colorectal cancer and beneficiary has had screening colonoscopy (G0121) within previous 10 years, screening flexible sigmoidoscopy is covered only after at least 119 months have passed following the month he/she received the G0121)

Coverage:

  • Aged 45 and older at normal risk for developing colorectal cancer; or
  • At high risk for developing colorectal cancer

Payment: Copayment/coinsurance waived; Deductible waived

  • If screening turns to diagnostic with PT modifier appended, special coinsurance percentage phase-in; Calendar Year (CY):
    • CY 2023-2026, coinsurance 15%
    • CY 2027-2029, coinsurance 10%
    • Beginning CY 2030 and beyond, no coinsurance
Screening Colonoscopy

HCPCS:

  • G0105 - Colonoscopy (high risk)
  • G0121 - Colonoscopy (not high risk)

Frequency:

  • High risk: Once every 24 months (unless screening flexible sigmoidoscopy was performed, then covered only after at least 47 months)
  • Not high risk: Once every 10 years or 48 months after previous sigmoidoscopy

Payment: Copayment/coinsurance waived; Deductible waived

  • If screening turns to diagnostic with PT modifier appended, special coinsurance percentage phase-in; Calendar Year (CY):
    • CY 2023-2026, coinsurance 15%
    • CY 2027-2029, coinsurance 10%
    • Beginning CY 2030 and beyond, no coinsurance

Surveillance Colonoscopy

Medicare does not specifically state whether a colonoscopy for "Surveillance" purposes is considered screening or diagnostic exclusively. Rather, it depends on the colonoscopy determination of billing:

  • Procedure reason and clinical circumstances

Example:

  • Patient has personal history of polyps and meets characteristics of high-risk individual
  • Physician states "surveillance" for next colonoscopy
    • Could be considered high-risk screening utilizing HCPCS G0105
  • Colonoscopy performed at three years and falls within interval timeframe for Medicare reimbursement

When a screening colonoscopy (routine or high-risk screening) procedure becomes more consistent with a diagnostic colonoscopy (based on findings, biopsy, additional required intervention, etc.), the coding will change to a diagnostic procedure. Append -PT modifier to signify the intraprocedural status change.

Screening Barium Enema

HCPCS:

  • G0106 - Barium Enema (alternative to G0104)
  • G0120 - Barium Enema (alternative to G0105)

Frequency:

  • High risk: Once every 24 months (when used instead of flexible sigmoidoscopy or colonoscopy)
  • Not high risk: Once every 48 months (when used instead of flexible sigmoidoscopy or colonoscopy)

Coverage:

  • Aged 45 and older at normal risk for developing colorectal cancer; or
  • At high risk for developing colorectal cancer

Payment: Copayment/coinsurance applies; Deductible waived

High Risk Conditions
  • Close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
  • Family history of familial adenomatous polyposis
  • Family history of hereditary nonpolyposis colorectal cancer
  • Personal history of adenomatous polyps
  • Personal history of colorectal cancer
  • Personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis
Resources
Noridian Medicare Portal Yes - 81528, 82270, G0104, G0105, G0106, G0120, G0121 and G0328

 

Counseling to Prevent Tobacco Use

Category Coverage and Benefit Resources
HCPCS/CPT Codes
  • 99406 - Smoking and tobacco-use cessation counseling visit; intermediate, greater than three minutes up to 10 minutes
  • 99407 - Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes
Frequency Two cessation attempts per year

Each attempt may include four intermediate or intensive sessions, with the total covering up to eight sessions per year
Diagnosis Codes
  • F17.210 - Nicotine dependence, cigarettes, uncomplicated
  • F17.211 - Nicotine dependence, cigarettes, in remission
  • F17.213 - Nicotine dependence, cigarettes, with withdrawal
  • F17.218 - Nicotine dependence, cigarettes, with other nicotine-induced disorders
  • F17.219 - Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders
  • F17.220 - Nicotine dependence, chewing tobacco, uncomplicated
  • F17.221 - Nicotine dependence, chewing tobacco, in remission
  • F17.223 - Nicotine dependence, chewing tobacco, with withdrawal
  • F17.228 - Nicotine dependence, chewing tobacco, with other nicotine-induced disorders
  • F17.229 - Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders
  • F17.290 - Nicotine dependence, other tobacco product, uncomplicated
  • F17.291 - Nicotine dependence, other tobacco product, in remission
  • F17.293 - Nicotine dependence, other tobacco product, with withdrawal
  • F17.298 - Nicotine dependence, other tobacco product, with other nicotine-induced disorders
  • F17.299 - Nicotine dependence, other tobacco product, with unspecified nicotine-induced disorders
  • T65.211A - Toxic effect of chewing tobacco, accidental (unintentional), initial encounter
  • T65.212A - Toxic effect of chewing tobacco, intentional self-harm, initial encounter
  • T65.213A - Toxic effect of chewing tobacco, assault, initial encounter
  • T65.214A - Toxic effect of chewing tobacco, undetermined, initial encounter
  • T65.221A - Toxic effect of tobacco cigarettes, accidental (unintentional), initial encounter
  • T65.222A - Toxic effect of tobacco cigarettes, intentional self-harm, initial encounter
  • T65.223A - Toxic effect of tobacco cigarettes, assault, initial encounter
  • T65.224A - Toxic effect of tobacco cigarettes, undetermined, initial encounter
  • T65.291A - Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter
  • T65.292A - Toxic effect of other tobacco and nicotine, intentional self-harm, initial encounter
  • T65.293A - Toxic effect of other tobacco and nicotine, assault, initial encounter
  • T65.294A - Toxic effect of other tobacco and nicotine, undetermined, initial encounter; or
  • Z87.891 - Personal history of nicotine dependence, unspecified, uncomplicated
Coverage

Outpatient and hospitalized beneficiaries who meet all of the following:

  • Use tobacco
  • Competent and alert at time of counseling
  • Counseling furnished by qualified physician or other Medicare-recognized practitioner
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

COVID-19 Vaccine, Monoclonal Antibodies and Administration

Category Coverage and Benefit Resources
HCPCS/CPT Codes

CMS has started the process of closing out the effective dates for certain COVID vaccines and monoclonal antibodies. Please see CMS COVID-19 Vaccines and Monoclonal Antibodies page for the most up-to-date list of these codes, including their effective date periods.

New CPT effective October 3, 2023:

  • 91304 - COVID-19 Vaccine, 5 mcg/0.5 mL
    • With CPT 90480 COVID-19 Vaccine Administration below
    • Beneficiary cost-sharing waived

New CPTs effective September 11, 2023:

  1. 90480 - COVID-19 Vaccine Administration
  2. 91318 - COVID-19 Vaccine, 3 mcg/0.2 mL
  3. 91319 - COVID-19 Vaccine, 10 mcg
  4. 91320 - COVID-19 Vaccine, 30 mcg
  5. 91321 - COVID-19 Vaccine, 25 mcg
  6. 91322 - COVID-19 Vaccine, 50 mcg
Coverage
  • All Medicare beneficiaries
  • Original Medicare no longer pays COVID-19 vaccine or monoclonal antibody product administration claims for Medicare Advantage beneficiaries on or after January 1, 2022, unless the beneficiary in a Medicare Advantage plan has chosen to enroll in hospice.
Payment Copayment/coinsurance waived; Deductible waived
Pricing For payment rates for COVID-19 vaccine administration, visit the COVID-19 Vaccine and Monoclonal Antibodies Pricing webpage on CMS.
Resources

 

Depression Screening

Category Coverage and Benefit Resources
HCPCS/CPT Codes

G0444 - Annual depression screening, 5-15 minutes

Frequency Annually
Coverage
  • All Medicare beneficiaries are eligible
  • Must be furnished in primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up

Coverage is limited to screening services and does not include treatment options for depression or any diseases, complications, or chronic conditions resulting from depression, nor does it address therapeutic interventions such as pharmacotherapy, combination therapy (counseling and medications), or other interventions for depression

Depression Screening cannot be done the same time as the initial AWV or Initial Preventive Physical Exam (IPPE)

Payment

Copayment/coinsurance waived; Deductible waived

Resources
Noridian Medicare Portal Yes - G0444

 

Diabetes Screening

Category Coverage and Benefit Resources
HCPCS/CPT Codes
  • 82947 - Glucose; quantitative, blood
  • 82950 - Glucose; post glucose dose
  • 82951 - Glucose; tolerance test, three specimens
Frequency

Beneficiaries diagnosed with pre-diabetes: Two screening tests per year

  • Use modifier TS to indicate beneficiary is pre-diabetic

Beneficiaries previously tested by not diagnosed with pre-diabetes or never tested: One screening per year

Diagnosis Code

Z13.1 - Encounter for screening for diabetes mellitus

Coverage

Medicare beneficiaries with certain risk factors or diagnosed with pre-diabetes

Risk factors:

  • Any one:
    • Hypertension
    • Dyslipidemia
    • Obesity
    • Previous identification of elevated impaired fasting glucose or glucose tolerance
  • Any two:
    • Overweight
    • Family history
    • Age 65 or older
    • History of gestational diabetes mellitus or delivering baby weighing over nine pounds
This screening is noncovered for beneficiaries previously diagnosed as diabetic
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - 82947, 82950 and 82951

 

Diabetes Self-Management Training (DSMT)

Category Coverage and Benefit Resources
HCPCS/CPT Codes
  • G0108 - DSMT, individual, per 30 minutes
  • G0109 - DSMT, group (two or more people), per 30 minutes
Frequency Initial Year: Up to 10 hours of initial training within a continuous 12-month period

Subsequent Years: Up to two hours of follow-up training each year after the initial year
Coverage

Beneficiary must meet both of the following:

  • Diagnosed with diabetes
  • Receive order for DSMT from physician or qualified non-physician practitioner treating beneficiary's diabetes
Payment Copayment/coinsurance applies; Deductible applies
Resources
Noridian Medicare Portal No

 

Glaucoma Screening

Category Coverage and Benefit Resources
HCPCS/CPT Codes
  • G0117 - By optometrist or ophthalmologist
  • G0118 - Under direct supervision of optometrist or ophthalmologist
Frequency Annually
Diagnosis Code

Z13.5 - Encounter for screening for eye and ear disorders

Coverage

Must fall into one category:

  • Have diabetes mellitus
  • Have family history of glaucoma
  • African-Americans aged 50 and older
  • Hispanic-Americans aged 65 and older
Exam Requirements

Medicare will pay for glaucoma screening examinations where they are furnished by or under direct supervision in office setting of an ophthalmologist or optometrist, who is legally authorized to perform services under State law

Screening for glaucoma is defined to include:

  • A dilated eye examination with an intraocular pressure measurement; and
  • A direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination
Payment Copayment/coinsurance applies; Deductible applies
Resources
Noridian Medicare Portal Yes - G0117 and G0118

 

Hepatitis B Virus (HBV) Screening

Category Coverage and Benefit Resources
HCPCS/CPT Codes

Asymptomatic, Non-pregnant Adolescents and High-Risk Adults

G0499 - Hepatitis b antibody screening in non-pregnant, high risk individual includes hepatitis b surface antigen (hbsag), antibodies to hbsag (anti-hbs) and antibodies to hepatitis b core antigen (anti-hbc), and is followed by a neutralizing confirmatory test, when performed, only for an initially reactive hbsag result

For Pregnant Women

86704 - Hepatitis B core antibody (HBcAb); total

86706 - Hepatitis B surface antibody (HBsAb)

87340 - Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; hepatitis B surface antigen (HbsAg)

87341 - Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; hepatitis B surface antigen (HbsAg) neutralization

Frequency
  • 1 asymptomatic screening for non-pregnant adolescents and adults who meet high-risk definition
  • Annually for patients with continued high risk who don’t get HBV
  • 1 screening for pregnant women at first prenatal visit for each pregnancy, and rescreening at delivery for those with new or continued risk factors
    • This includes pregnant patients who previously got the HBV shot or had a negative hepatitis B surface antigen screening result
Diagnosis Code

Persons with ESRD:

  • Z11.59 and N18.6

Asymptomatic, Non-pregnant Adolescents and High-Risk Adults:

  • Z11.59 and Z72.89

Asymptomatic, Non-pregnant Adolescents and Adults, Subsequent Visits:

  • Z11.59 and 1 code from pages 22-26 in CR12377

Pregnant Women:

  • Z11.59 and 1 of these: Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93

High-Risk Pregnant Women:

  • Z11.59 and Z72.89 and 1 of these: O09.90, O09.91, O09.92, O09.93
Coverage

Ordered by primary care physician or practitioner; and

Beneficiary must be either be:

  • High risk for HBV infection, asymptomatic, and non-pregnant:
    • Persons born in regions with a high prevalence of HBV infection
    • US-born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection
    • HIV-positive
    • Men who have sex with men
    • Injection drug users
    • Household contacts or sexual partners of persons with HBV infection
  • Pregnant women
Payment No copayment, coinsurance, or deductible
Resources
Noridian Medicare Portal Yes - G0499

 

Hepatitis B Virus (HBV) Vaccine and Administration

Category Coverage and Benefit Resources
HCPCS/CPT Codes
  • 90739 - Hepatitis B vaccine, adult dosage (two dose schedule), for intramuscular use
  • 90740 - Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (three dose schedule), for intramuscular use
  • 90743 - Hepatitis B vaccine, adolescent (two dose schedule), for intramuscular use
  • 90744 - Hepatitis B vaccine, pediatric/adolescent dosage (three dose schedule), for intramuscular use
  • 90746 - Hepatitis B vaccine, adult dosage (three dose schedule), for intramuscular use
  • 90747 - Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (four dose schedule), for intramuscular use
  • 90759 - Hepatitis B vaccine, 3-antigen, 10 mcg dosage (3 dose schedule), for intramuscular use
  • G0010 - Administration of Hepatitis B vaccine
Frequency Scheduled doses required
Diagnosis Code

Z23 - Encounter for immunization

Coverage

Intermediate risk

  • Staff at institutions for mentally challenged
  • Workers who have frequent contact with blood or blood-derived body fluids

High risk

  • End Stage Renal Disease (ESRD) patients
  • Clients of institutions for mentally challenged
  • Someone who lives in same house as a hepatitis b virus carrier
  • Homosexual men
  • Someone who injects illicit drugs

Medicare beneficiaries currently positive for antibodies for hepatitis B are not eligible for this benefit

Payment

Copayment/coinsurance waived; Deductible waived

G0010 allows $30 (2022)

Resources
Noridian Medicare Portal No

 

Hepatitis C Virus (HCV) Screening

Category Coverage and Benefit Resources
HCPCS/CPT Codes

G0472 - Hepatitis C antibody screening, for individual at high risk and other covered indication(s)

Frequency
  • Annually only for high risk beneficiaries with continued illicit injection drug use since prior negative screening test
  • Once in a lifetime for beneficiaries born between 1945 and 1965 who are not considered high risk
  • Initial screening, regardless of birth year, who had a blood transfusion before 1992 and beneficiaries with current or past history of illicit injection drug use
Diagnosis Code

Initially high-risk

  • Z72.89 - Other problems related to lifestyle

High risk with continued illicit injection drug use since prior screening

  • Z72.89 - Other problems related to lifestyle; and
  • F19.20 - Other psychoactive substance dependence, uncomplicated
Coverage
  • Ordered by primary care physician or practitioner; and
  • Beneficiary must be either be:
    • High risk for HCV infection
      • Persons with current or past history of illicit injection drug use
      • History of receiving blood transfusion prior to 1992
    • Born between 1945 and 1965
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0472

 

Human Immunodeficiency Virus (HIV) Screening

Category Coverage and Benefit 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
Resources
Noridian Medicare Portal Yes - G0475

 

Resources

CMS has developed educational resources that are available for the provider community.

 

Last Updated Feb 21 , 2024