Coverage for hepatitis tests generally depends on appropriate documentation of signs and symptoms of disease, as explained in the September 2001 Pathology/Lab Coding Alert, "Know Laboratory Methods and Coverage Indications for Payment of Hepatitis Tests." However, special coverage rules allow testing in certain asymptomatic patients who are considered high-risk for contracting hepatitis.
Special coverage rules for hepatitis testing have been established for individuals undergoing repeat dialysis for end-stage renal disease (ESRD). Laboratories should be aware that the Office of Inspector General (OIG) identified "hepatitis tests to dialysis patients that were not reasonable and necessary for the diagnosis or treatment of illness at the frequency provided" as part of its 2001 work plan (available on the Internet at www.dhhs.gov/progorg/oig/wrkpln/2001/wp2001.pdf
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). Following approved hepatitis testing guidelines for these patients is imperative to avoid investigation for fraud.
Other asymptomatic patients, such as those exposed to infected blood, are subject to special coverage for hepatitis testing also. This includes certain transfusion recipients identified as part of the hepatitis C (HCV) "look-back" under Food and Drug Administration (FDA) guidelines. These patients received a blood transfusion prior to routine testing for HCV in 1992 and, based on subsequent testing, are believed to have received HCV-infected blood.
Hepatitis Tests Billed Separately for ESRD Patients
Many services for patients undergoing repeat dialysis for ESRD are reimbursed by Medicare at a composite rate. "However, hepatitis tests are not included in the ESRD composite rate and are billed separately," says Michelle Phillips, RHIT, medical records specialist for Gambro Healthcare Inc. in Nashville, Tenn., which operates more than 500 dialysis facilities throughout the United States. "Prior to the initial dialysis, patients are routinely tested to establish their immune status and susceptibility to hepatitis, and the results are used to determine future hepatitis testing requirements."
Initial testing for hepatitis B includes hepatitis B surface antigen (87340, HBsAg), the first indicator of acute infection or the indicator of chronic infection if the level remains elevated; and hepatitis B surface antibody (86706, HBsAb), the indicator for seroconversion from past infection or immunization, Phillips says.
Because patients who are tested for hepatitis before beginning dialysis do not necessarily exhibit signs or symptoms of disease, using the proper diagnosis code is crucial for the tests to be covered. "We report both 585 (chronic renal failure) and V45.1 (renal dialysis status) as the diagnosis codes for these patients," Phillips says. Billing for hepatitis B surface antibody and antigen for ESRD beneficiaries requires these dual diagnoses, according to Medicare direction. In its recent "Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients" in Morbidity and Mortality Weekly Report (MMWR, April 27, 2001), the Centers for Disease Control [...]