On February 5, 2016, CMS released change requests announcing the addition of HPV and HIV screenings to the National Coverage Determination (NCD) Manual. APS has summarized those policies for pathology/laboratory entities who, in turn, may want to forward this information to their referring physician offices.
Screening for Cervical Cancer with Human Papillomavirus (HPV) Co-Testing – CR 9434
Medicare covers a screening pelvic examination and pap test for all female beneficiaries every one or two years, based on designated risk factors. Coverage previously did not include HPV testing. Retroactive to date of service July 9, 2015, screening for HPV is now covered when performed in conjunction with a cervical cancer screening under the following conditions:
- Once every 5 years for asymptomatic beneficiaries aged 30 – 65 years
- G0476 has been created for reporting this test to Medicare
- Pricing will be through the individual Medicare Administrative Contractors (MAC) for services through December 31, 2016; beginning January 2017 pricing and payment will be through the Clinical Lab Fee Schedule
- To be eligible for coverage, a combination of two diagnoses must accompany G0476 differentiated by the outcome of the gynecological exam (normal vs abnormal) as explained in the below PDF.
The addition of this policy does not change current policy for pap smear screenings/pelvic examinations.
The full details of this policy are published in MLN Matters number MM9434 which can be accessed at:
Screening for Human Immunodeficiency Virus (HIV) Infection – CR 9403
CMS has determined that screening of HIV infection for specified categories of individuals is reasonable and necessary for early detection of HIV. Retroactive to date of service April 13, 2015, this screening is now covered when ordered by the beneficiary’s practitioner within the context of a healthcare setting for beneficiaries who meet one of the following conditions:
- Patients between 15 – 65 years without regard to perceived risk
- A maximum of one, annual, voluntary screening (except for pregnant Medicare beneficiaries)
- Younger or older patients who are at increased risk for HIV infection
- A maximum of one, annual, voluntary screening (except for pregnant Medicare beneficiaries)
- “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 have acquired or request testing for other sexually transmitted infectious diseases
- Person with a history of blood transfusions between 1978 and 1985
- Persons who requests an HIV test despite reporting no individual risk factors
- Person with new sexual partners
- Person who, based on the practitioner’s interview and examination, is deemed to be at increased risk for infection
- Pregnant women
- 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 patient’s clinician
- A maximum of three voluntary HIV screenings of pregnant Medicare beneficiaries:
- G0475 has been created for reporting this service to Medicare
- To be eligible for coverage, G0475 must be accompanied by the appropriate diagnosis(es) reflecting the service and patient’s status as explained in the below PDF.
- Please note the degree of specificity that will be needed for proper code assignment of the secondary diagnoses
The full details of this policy are published in MLN Matters number MM9403 which can be accessed at:
Proper code assignment is based on the documentation in the final pathology report. As such, APS Medical Billing maintains processes to review reports for documentation that supports the assignment of diagnosis codes that are on the approved list.
