Preventive Services

Preventive Services Guide


Hepatitis C Virus Screening

Hepatitis C is a virus that can damage the liver; it is transmitted through infected blood or body fluids. The most common way people get infected is by sharing needles used to inject drugs. Each year, more than 15,000 people in the United States are thought to die of complications from chronic hepatitis C infection. It is possible to have hepatitis C but not develop any symptoms for decades.

Coverage Criteria

  • Medicare beneficiaries who fall into at least one of these categories are covered:
    • High risk for HCV infection
    • Born between 1945 and 1965
      • A single once in a lifetime screening test for those who do not meet high risk (use ICD-10 Z11.59)
    • Had a blood transfusion before 1992
      • Initial screening for beneficiaries and beneficiaries with current or past history of illicit injection drug use
  • Covered annually only for high-risk Medicare beneficiaries with continued illicit injection drug use since the prior negative screening test

HCPCS/CPT Coding

  • G0472: Hepatitis C antibody screening for individual at high risk and other covered indication(s), will be used

ICD-10 Diagnosis Coding

  • Z72.89: Other problems related to lifestyle
  • Z11.59: Encounter for screening for other viral diseases
  • F19.20: Other psychoactive substance abuse, uncomplicated

Additional ICD-10 codes may apply. See the CMS ICD-10 webpage for individual CRs and the specific ICD-10-CM codes Medicare covers for this service, and contact your Medicare Administrative Contractor (MAC) for guidance.

Who Can Perform?

  • 01 – General practice
  • 08 – Family practice
  • 11 – Internal medicine
  • 16 – Obstetrics/gynecology
  • 37 – Pediatric medicine
  • 38 – Geriatric medicine
  • 42 – Certified nurse midwife
  • 50 – Nurse practitioner
  • 89 – Certified clinical nurse specialist
  • 97 – Physician assistant

For professional claims with dates of service on or after 6/2/2014, CMS will allow coverage for HCV screening, HCPCS G0472, only when submitted with one of the following POS codes:

  • 11 – Physician’s office
  • 22 – Outpatient hospital
  • 49 – Independent clinic
  • 71 – State or local public health clinic
  • 81 – Independent laboratory

Cost Sharing

  • Copayment/coinsurance waived
  • Deductible waived

Reimbursement

Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

Common Claim Denial Reasons

  • The prescribing/ordering provider is not eligible to prescribe/order the service
  • Payment denied when performed by this type of provider in this type of facility
  • Benefit maximum for this time period or occurrence has been reached

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Reviewed 9/27/2024