MEDICARE COVERS HIV TESTING...BUT ONLY IF YOU USE THE RIGHT CODE (Z11.4 for ICD10, FORMERLY V73.89 for ICD9)! AND OTHER INSURANCE MAY USE DIFFERENT CODES...

(Updated 10/28/15 for ICD-10; original article 12/21/13))

We thought we had it all solved four years ago. On December 8, 2009, Medicare announced that it would start covering the cost of annual HIV screening for all beneficiaries regardless of age, diagnosis, or risk indication, at no cost to the patient.  (Click here to read the story behind the approval, including the testimony from Beyond AIDS to the Center for Medicare and Medicaid Services, or CMS.) One might assume that if a test is free and does not require a special diagnosis or risk as an indication, coverage should be approved regardless of what codes are entered for billing. But one would be wrong! That's not how government, healthcare, or insurance work.

Beyond AIDS had originally become involved in 2009 when a member on Medicare was billed $77 by a lab because HIV testing was not a covered benefit. Four years after Medicare agreed to cover HIV screening, the same thing happened, only this time the lab bill was $169! Knowing that the test was supposed to be covered, our member appealed and asked for an explanation. It turned out that the doctor had used the "wrong" ICD diagnostic code.

When the physician was told of the correct code (which we're revealing to you here), the billing was revised. However, the lab initially neglected to pass on the corrected code to Medicare, and instead began sending the patient threatening letters from its collection agency. Eventually, the charge for the test was cancelled, but the lack of transparency on the part of CMS, combined with high charges and negligence by the lab, had meanwhile resulted in a lot of avoidable stress.

The good news is that for right now, providers can use the information in this posting and enter ICD-10 code Z11.4, to assure coverage of a routine EIA screening test on a Medicare patient.

ICD-10 code Z11.4 is an encounter for HIV screening, which the provider should enter on the lab requisition, and may also bill if there is no other diagnosis for the visit (this was formerly V73.89 under ICD-9). If there is special high risk, the additional code Z72.89 should be added. Medicare's requirement for codes for patients not complaining of a specific risk factor for HIV is not publicized, and is very difficult for physicians to locate with Web searches. This makes the promise of coverage for screening of all beneficiaries almost meaningless for practical purposes.

There are other codes that providers will generally not need to include in billing. The HCPCS code G0432 (infectious agent antibody detection by EIA technique) identifies an ELISA (EIA) combined HIV-1 and 2. If it is a rapid test, the code is G0435 (infectious agent antibody detection by rapid antibody test). According to CMS publication ICN 006559, October 2015, appropriate HCPCS codes for an HIV screening test depend on technique used.

Since the start of the Affordable Care Act ("Obamacare") at the beginning of 2014, all medical insurance coverages affected by the law (not just Medicare) are required to cover HIV screening at no cost to patients. That requirement is based on a strong (Class A) recommendation for routine and universal HIV screening of all persons ages 15 to 65, by the U.S. Preventive Services Task Force (USPSTF), in April 2013.  In addition to HIV testing, a number of other preventive services, including tests, immunizations, and treatments, will be covered by all qualified insurance plans under the law, especially for women. Hopefully, each insurance plan will agree to use the same codes as Medicare for the free screening. If an insurance plan were to select its own obscure code for the coverage of HIV screening and for each of the other preventive tests, that would present a barrier to preventive screening.

Additional issues are raised by this experience. Our member was required to obtain the HIV test by a healthcare employer. The legality of such a requirement will not be dealt with here, but is problematic. The lab charge for a simple HIV antibody screening when insurance apparently does not apply was already exorbitant in 2009, and increased by 119% in just 4 years. So it's a good thing that the country is moving toward free, routine HIV screening. But the billing code requirements that are currently used in the U.S. are not going to make that a simple matter.

The take-home pearl here is that Medicare providers should use ICD-10 code Z11.4, and Medicare patients who want an HIV test should  pass that information on to providers to avoid getting big bills from labs. But that's just for Medicare, and it might even change in the future. This is only the tip of the iceberg, because different codes may be used by a myriad of insurance plans, and for other newly covered tests and procedures as well as HIV testing. Medical organizations and insurance plans should determine and publicize the ICD-10 codes that must be used for billing each of the newly covered preventive services under the Affordable Care Act. The Beyond AIDS Foundation will continue to follow this issue.