CMS Pub. 100-04, ch. 18, § 230

Effective for services furnished on or after September 28, 2016, an initial screening for hepatitis B virus

infection (HBV) is covered for asymptomatic, non-pregnant adolescents and adults at high risk for HBV

infection. “High risk” is defined as persons born in countries and regions with high prevalence of HBV

infection (i.e., ≥ 2%), US-born persons not vaccinated as infants whose parents were born in regions with a

very high prevalence of HBV infection (i.e., ≥ 8%), HIV-positive persons, men who have sex with men,

injection drug users, household contacts or sexual partners of persons with HBV infection.

In addition, CMS has determined that repeated screening would be appropriate annually only for beneficiaries

with continued high risk (men who have sex with men, injection drug users, household contacts or sexual

partners of persons with HBV infection) who do not receive hepatitis B vaccination.

A screening test at the first prenatal visit is covered for pregnant women and then rescreening at time of

delivery for those with new or continuing risk factors. In addition, CMS has determined that screening during

the first prenatal visit would be appropriate for each pregnancy, regardless of previous hepatitis B vaccination

or previous negative hepatitis B surface antigen (HBsAg) test results. See section 170 of this chapter for

coverage and billing instructions for pregnant beneficiaries.

Effective for claims with dates of service on or after September 28, 2016, the claims processing instructions

for payment of screening for hepatitis B virus will apply to the following HCPCS and CPT codes:

• HBV screening for asymptomatic, non-pregnant adolescents and adults at high risk - code G0499

• HBV screening for pregnant women – CPT codes 86704, 86706, 87340 and 87341

A. Frequency

HBV screening for asymptomatic, non-pregnant adolescents and adults at high risk (HCPCS code

G0499)

• A single, one-time screening test is covered for asymptomatic, non pregnant adolescents and adults

who do meet the high risk definition above.

• Repeat screening for high risk persons is covered annually only for persons who have continued high

risk who do not receive hepatitis B vaccination .

Note: Annual means a full 11 months must elapse following the month in which the previous negative

screening took place.

Note for ESRD: Effective for claims with dates of service on or after September 28, 2016 submitted with

G0499 – “HepB screen high risk indiv, for asymptomatic non-pregnant beneficiaries” and ICD-10 diagnosis

code N18.6, End Stage Renal Disease, all of the preceding requirements shall be bypassed and the claim shall

be allowed to pay, no matter what other ICD-10 diagnosis codes may appear on the claim.

HBV screening for pregnant women (CPT codes 86704, 86706, 87340 and 87341)

• One occurrence per pregnancy of screening for HBV in pregnant women, and

• One additional occurrence per pregnancy of screening for HBV in pregnant women who are at

continued risk

B. Determination of High Risk for Hepatitis B Disease

The determination of “high risk for HBV” is identified by the primary care physician or practitioner who

assesses the patient’s history, which is part of any complete medical history, typically part of an annual

wellness visit, and considered in the development of a comprehensive prevention plan. The medical record

should be a reflection of the service provided.

Note: See Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual §210.6 for complete

coverage guidelines.