(Medicare Claims Processing Manual)

 80081 -   Obstetric panel   130.2 - Billing Requirements (Rev.  3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17) Medicare Administrative Contractors (MACs) shall recognize the above HCPCS codes for HIV screening in accordance with Publication 100- 03, Medicare National Coverage Determinations Manual, section 210.7.  Effective for claims with dates of service on and after December 8, 2009, MACs shall pay for voluntary HIV screening as follows :   A maximum of once annually for beneficiaries at increased risk for HIV infection (11 full months must elapse following the month the previous test was performed in order for the subsequent test to be covered), and,    A maximum of three times per term of pregnancy for pregnant Medicare beneficiaries beginning with the date of the first test when ordered by the womans clinician.   Claims that are submitted for HIV screening shall be submitted in the following manner:   For beneficiaries reporting increased risk factors, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 (Special screening for other specified viral disease) as primary, and V69.8 (Other problems related to lifestyle), as seco ndary.   For beneficiaries not reporting increased risk factors, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 only.  For pregnant Medicare beneficiaries, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 as primary, and one of the following ICD -9 diagnosis codes: V22.0 (Supervision of normal first pregnancy), V22.1 (Supervision of other normal pregnancy), or V23.9 (Supervision of unspecified high- risk pregnancy), as secondary.   Effective for claims with dates of service on or after April 13, 2015, MACs shall also pay for voluntary, HIV screening as follows  (replacing ICD -9 with ICD -10 beginning October 1, 2015):   For pregnant Medicare beneficiaries , claims shall contain HCPCS code G0432, G0433, G0435, G0475 or CPT-80081 with primary ICD -9/ICD -10 diagnosis code V73.89/Z11.4, along with one of the following ICD -9/ICD -10 diagnosis codes as secondary listed below, and allow no more than 3 HIV screening tests during each term of pregnancy beginning with the date of the 1st test:   ICD-9:  V22.0 Supervision of normal first pregnancy  ICD-10:  Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester  Z34.01 Encounter for supervision of normal first pregnancy, first trimester  Z34.02 Encounter for supervision of normal first pregnancy, second trimester  Z34.03 Encounter for supervision of normal first pregnancy, third trimester  ICD-9:  V22.1 Supervision of other normal pregnancy  ICD-10:  Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester  Z34.81 Encounter for supervision of other normal pregnancy, first trimester  Z34.82 Encounter for supervision of other normal pregnancy, second trimester  Z34.83 Encounter for supervision of other normal pregnancy, third trimester  Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester  Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester  Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester  Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester  ICD-9:  V23.9 Supervision of unspecified high- risk pregnancy ICD-10:  O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester  O09.91 Supervision of high risk pregnancy, unspecified, first trimester  O09.92 Supervision of high risk pregnancy, unspecified, second trimester  O09.93 Supervision of high risk pregnancy, unspecified, third trimester   For non- pregnant Medicare beneficiaries , claims shall contain HCPCS code G0432, G0433, G0435, or G0475 for beneficiaries between 15 and 65 years of age one time per annum with ICD -9/ICD -10 diagnosis code V73.89/Z11.4 as primary regardless of risk factors.  If primary ICD -9/ICD -10 diagnosis code  V73.89/Z11.4 is not present and the beneficiary is between 15 and 65 years of age, or the service is billed more than one time per annum, the detail line shall be denied.   For non- pregnant Medicare beneficiaries , claims shall contain HCPCS code G0432, G0433, G0435, or G0475 for beneficiaries less than 15 and greater than 65 years of age one time per annum with ICD -9/ICD -10 diagnosis code V73.89/ Z11.4 as primary, and one of the following secondary ICD -9/ICD -10 di agnosis codes:   V69.8 (Other problems related to lifestyle)/Z72.89 (Other problems related to lifestyle)  Z72.51 (High risk heterosexual behavior)  Z72.52 (High risk homosexual behavior)  Z72.53 (High risk bisexual behavior)   If ICD -9/ICD -10 diagnosis code V73.89/Z11.4 is not present as primary and one of the ICD -9/ICD -10 secondary codes listed above is not present and the beneficiary is less than 15 or greater than 65 years of age, or the service is billed more than one time p er annum, the detail line shall be denied.   130.3 - Payment Method  (Rev. 3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17)   Payment for HIV screening, HCPCS codes G0432, G0433, G0435, is under the Medicare Clinical Laboratory Fee Schedule (CLFS) for Types of Bill (TOB) 12X, 13X, 14X, 22X, and 23X beginning January 1, 2011.  For TOB 85X payment is based on reasonable cost.  Deductible and coins urance do not apply.  Between December 8, 2009, and April 4, 2010, these services can be billed with unlisted procedure code 87999.  Between April 5, 2010, and January 1, 2011, HCPCS codes G0432, G0433, and G0435 will be contractor priced.   Payment for HIV screening, HCPCS code G0475, for institutional claims will be under the Medicare CLFS for TOB 12X, 13X, 14X, 22X, and 23X for claims on or after January 1, 2017.  For TOB 85X payment is based on reasonable cost.  Effective for claims with date of service from April 13, 2015 through December 31, 2016, HCPCS code G0475 will be contractor priced.  Beginning with date of service January 1, 2017 and after, HCPCS code G0475 will be priced and paid according to the CLFS.  HCPCS code G0475 will be included in the January 2017 CLFS, January 1, 2016 IOCE, the January 2016 OPPS and January 1, 2016 MPFSD.  HCPCS code G0475 will be effective retroactive to April 13, 2015 in the IOCE & OPPS.   A/B MACs (B) shall only accept claims submitted with a G0475, G0432, G0433, or G0435 with a Place of Service (POS) Code equal to 81 Independent Lab, and 11, Office.   Deductible and coinsurance do not apply.   130.4 - Types of Bill (TOBs) and Revenue Codes  (Rev. 3461; Issued: 02- 05-16; Effective: 04 -13-15; Implementation: 03 -07-16 - non-shared A/B MAC edits; 07 -05-16 - CWF analysis and design; 10- 03-16 - CWF Coding, Testing and Implementation, MCS, and FISS Implementation; 01 -03-17 - Requirement 9403.04.9)   The applicable bill types for HIV screening, HCPCS codes G0432, G0433, G0435, and G0475 are: 12X, 13X, 14X, 22X, 23X, and 85X.  (Effective April 1, 2006, TOB 14X is for non- patient laboratory specimens.)  Use revenue code 030X (laboratory, clinical diagnos tic).  A/B MACs (A) shall apply contractor pricing for HCPCS code G0475, HIV screening, for claims with dates of service on and after April 13, 2015 through December 31, 2016.   130.5 - Diagnosis Code Reporting  (Rev. 3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17) A claim that is submitted for HIV screening shall be submitted with one or more of the following diagnosis codes in the header and pointed to the line item:   a. For claims where increased risk factors are reported : ICD -9/ICD -10 diagnosis code V73.89/Z11.4 as primary and ICD -9/ICD -10 diagnosis code V69.8/Z72.89, Z72.51, Z72.52, or Z72.53, as secondary.   b. For claims where increased risk factors are NOT reported : ICD -9/ICD -10 diagnosis code V73.89/Z11.4 as primary only.  c. For claims for pregnant Medicare beneficiaries , the following secondary diagnosis codes shall be submitted in addition to primary ICD -9/ICD -10 diagnosis code V73.89/Z11.4 to allow for more frequent screening than once per 12 -month period:   ICD-9: V22.0 Supervision of normal first pregnancy  ICD-10: Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester  Z34.01 Encounter for supervision of normal first pregnancy, first trimester  Z34.02 Encounter for supervision of normal first pregnancy, second trimester  Z34.03 Encounter for supervision of normal first pregnancy, third trimester   ICD-9:  V22.1 Supervision of other normal pregnancy  ICD-10: Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester  Z34.81 Encounter for supervision of other normal pregnancy, first trimester  Z34.82 Encounter for supervision of other normal pregnancy, second trimester  Z34.83 Encounter for supervision of other normal pregnancy, third trimester  Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester  Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester  Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester  Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester   ICD-9: V23.9 Supervision of unspecified high- risk pregnancy ICD-10: O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester  O09.91 Supervision of high risk pregnancy, unspecified, first trimester  O09.92 Supervision of high risk pregnancy, unspecified, second trimester  O09.93 Supervision of high risk pregnancy, unspecified, third trimester   130.6 - Medicare Summary Notice (MSN) and Claim Adjustment Reason Codes (CARCs)  (Rev.  3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17)  Effective for dates of service on or after December 8, 2009, when denying claims for HIV screening, HCPCS codes G0432, G0433, or G0435, submitted without ICD -9/ICD -10 diagnosis codes V73.89/Z11.4, or V73.89/Z11.4 and V69.8/Z72.89, use the following message s:  Medicare Summary Notice (MSN) 16.10 -  Medicare does not pay for this item or service.   Medicare no paga por este articulo o servicio   Claim Adjustment Reason Code (CARC) 167-  This (these) diagnosis(es) is (are) not covered.   Group Code CO -  (Contractual Obligation)    Effective for dates of service on or after December 8, 2009, when denying claims for HIV screening, HCPCS codes G0432, G0433, or G0435, over the benefit maximum, use the following denial messages:   MSN 15.22  The information provided does not support the need for this many services or items in this period of time so Medicare will not pay for this item or service.