Preventive Services

Preventive Services Guide


Human Immunodeficiency Virus Screening

HIV attacks cells that help the body fight infection making a person vulnerable to other infections. Nearly 1.2 million Americans are now living with HIV infection and about 50,000 people become infected every year.

Coverage Criteria and Frequency Limits

  • Covered annually for beneficiaries at increased risk for HIV infection
  • Covered for a maximum of three times per term of pregnancy for pregnant Medicare beneficiaries
    • When diagnosis of pregnancy is known
    • During the third trimester
    • At labor, if ordered by woman’s physician
  • Coverage provided for both standard and FDA approved HIV rapid-screening tests

Increased Risk Factors

  • Men who have had sex with men after 1975
  • Men and women having unprotected sex with multiple partners
  • Past or present injection drug users
  • Men and women who exchange sex for money or drugs or who have sex partners who have
  • Individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users
  • Individuals being treated for STDs
  • Individuals with history of blood transfusion between 1978 and 1985
  • Individuals who request HIV test despite reporting no individual risk factors

HCPCS/CPT Coding

  • G0432: Infectious agent antibody detection by EIA technique, HIV-1 or HIV-2, screening
  • G0433: Infectious agent antibody detection by ELISA technique, HIV-1 and/or HIV-2, screening
  • G0435: Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening
  • G0475: HIV antigen/antibody, combination assay, screening
  • 80081: Obstetric panel (includes HIV testing)

Diagnosis Coding

  • ICD-10 Codes
    • Increased risk factors not reported – Z11.4
    • Increased risk factors reported – Z11.4 and Z72.51, Z72.52, Z72.53, or Z72.89
    • Pregnant Medicare beneficiaries – Z11.4 and Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, or O09.93
  • Note: Additional ICD-10 codes may apply. See the CMS ICD-10 webpage for individual Change Requests (CRs) and the specific ICD-10-CM codes Medicare covers for this service, and contact your Medicare Administrative Contractor (MAC) for guidance

Cost Sharing

  • Copayment/coinsurance waived
  • Deductible waived

Reimbursement

Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

Common Claim Denial Reasons

  • Beneficiary received HIV screening within past year (not because of pregnancy)
  • Beneficiary already received three HIV screenings within current pregnancy

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Reviewed 9/27/2024