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

MPFS: Fee Schedule Lookup

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