CMS Pub. 100-04, ch. 18, § 130.3

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 coinsurance 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 diagnostic).

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