CPT CODE G0475 COVEREAGE Guidelines and frequency – Part 1

Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that screening of HIV infection for all individuals between the ages of 15-65 years is reasonable and necessary for early detection of HIV, and it is appropriate for individuals entitled to benefits under Part A or enrolled in Part B.

On January 1, 2009, CMS was authorized to add coverage of “additional preventive services” through the National Coverage Determination (NCD) process if certain statutory requirements are met. One of those requirements is that the service(s) be categorized as a grade A (strongly ecommends) or grade B (recommends) rating by the United States Preventive Services Task Force (USPSTF) and meets certain other requirements. Previously, the USPSTF strongly recommended screening for all adolescents and adults at increased risk for HIV infection, as well as all pregnant women. The USPSTF made no recommendation for or against routine HIV screening in adolescents and adults not at increased risk for HIV infection. Effective December 8, 2009, CMS issued a final decision supporting the USPSTF recommendations.

In April 2013, the USPSTF updated these recommendations and recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened (Grade A recommendation). The USPSTF also recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown (Grade A recommendation).

CR 9403 instructs that effective for claims with dates of service on and after April 13, 2015, CMS will cover screening for HIV with the appropriate U.S. Food and Drug Administration (FDA)-approved laboratory tests and point-of-care tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations, when ordered by the beneficiary’s physician or practitioner within the context of a healthcare setting and performed by an eligible Medicare provider for these services, for beneficiaries who meet one of the following conditions below:

  1. Except for pregnant Medicare beneficiaries addressed below, a maximum of one, annual, voluntary screening for all adolescents and adults between the ages of 15 and 65, without regard to perceived risk.
  2. Except for pregnant Medicare beneficiaries addressed below, a maximum of one, annual, voluntary screening for adolescents younger than 15 and adults older than 65 who are at increased risk for HIV infection. Increased risk for HIV infection is defined as follows:

• Men who have sex with men;
• Men and women having unprotected vaginal or anal intercourse;
• 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 HIV-infected, bisexual, or injection drug users;• Persons who request an HIV test despite reporting no individual risk factors;
• Persons with new sexual partners; or
• Persons who, based on individualized physician interview and examination, are deemed to be at increased risk for HIV infection. The determination of “increased risk” for HIV infection is identified by the health care practitioner who assesses the patient’s history, which is part of any complete medical history, typically part of an
annual wellness visit and considered in the development of a comprehensive prevention plan. The medical recommendation should be a reflection of the service

  1. A maximum of three voluntary HIV screenings of pregnant Medicare beneficiaries:

** When the diagnosis of pregnancy is known;
** During the third trimester; and
** At labor, if ordered by the woman’s clinician.

NOTE: There is no co-insurance or deductible for tests paid under the Clinical Laboratory Fee Schedule (CLFS).

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