CMS Pub. 100-04, ch. 18, § 130.2

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 woman’s 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 secondary.

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 diagnosis 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 per annum, the detail line shall be denied.