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ICD-10: Include Appropriate Diagnosis Codes to Support Coverage for G0475


- Published on Thu, Jul 21, 2016

Here’s what to do for pregnant patients.

When reporting G0475 (HIV antigen/antibody, combination assay, screening) for screening a Medicare-covered patient for HIV infection, you will have to report appropriate diagnosis codes to help support the necessity of screening and to allow coverage to obtain reimbursement for the screening.

When the screening for HIV is performed for a patient aged between 15 to 65 without regard to the risk of HIV, your claim for G0475 should be reported with the primary diagnosis code as Z11.4 (Encounter for screening for human immunodeficiency virus [HIV]). For individuals aged below 15 or older than 65 who are at increased risk of HIV, your claim for G0475 should be supported with the same primary diagnosis code, Z11.4.

However, for individuals aged below 15 or older than 65 who are at increased risk of HIV, you should report an additional diagnosis code that denotes the high risk of HIV infection. The secondary diagnosis codes that denote increased risk of HIV  include:

  • Z72.51 (High risk heterosexual behavior)
  • Z72.52 (High risk homosexual behavior)
  • Z72.53 (High risk bisexual behavior)
  • Z72.89 (Other problems related to lifestyle).

For pregnant women, when you are reporting G0475 for a HIV screening, you have to report Z11.4 as the primary diagnosis code. You will have to report an additional secondary diagnosis code, such as Z34.0- (Encounter for supervision of normal first pregnancy…), Z34.8- (Encounter for supervision of other normal pregnancy…), Z34.9- (Encounter for supervision of normal pregnancy, unspecified…) or O09.9- (Supervision of high risk pregnancy, unspecified…). But be careful.  Under ICD-10 rules, the obstetric complication code (in this case O09.9-) must be listed as the primary diagnosis, but under the CMS rule, the Z11.4 screening code is required as the primary diagnosis for the pregnant patient.

Resources: For more information on screening for HIV, see the MLMatters article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9403.pdf.






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