CMS Pub. 100-04, ch. 18, § 230.1

Effective for claims with dates of service on or after September 28, 2016, providers may use the following

types of bill (TOBs) when submitting claims for HBV screening, HCPCS G0499, 86704, 86706, 87340, and

87341: 13X, 14X, 72X, and 85X. Deductible and coinsurance do not apply. Service line-items on other TOBs

shall be denied.

The service shall be paid on the basis shown below:

• Outpatient hospitals – TOB 13X - based on Outpatient Prospective Payment System

• Non-patient laboratory specimen – TOB 14X – based on laboratory fee schedule

• End Stage Renal Disease facilities (ESRDs) – TOB 72X – based on ESRD PPS when submitted with code

G0499 and diagnosis code N18.6. HBV is not separately payable for (ESRD TOB 72X) unless reported

with Modifier AY.

• Critical Access Hospitals (CAHs) - TOB 85X – based on reasonable cost when the revenue code is not

096X, 097X, and 098X

Note: For outpatient hospital settings, as in any other setting, services covered under this NCD must be

provided by a primary care provider.

NOTE: Beneficiary coinsurance and deductibles do not apply to claim lines containing HCPCS G0499, and

CPT codes 86704, 86706, 87340, and 87341.

NOTE: Medicare Administrative Contractors shall contractor-price HBV screening claims, HCPCS G0499,

with dates of service September 28, 2016 through December 31, 2017.