The percentage of people who have hepatitis B but don’t know it could be as high as 67 percent, and the opioid epidemic is fueling an increase in infections, according to the Department of Health and Human Services (HHS). That’s one reason screening is so important. Medicare’s coverage rules for hepatitis B screening are specific, though, so let’s nail down the professional coding rules for screening of non-pregnant patients.
Know the Beneficiaries Involved and Frequency Limits
The rules we’re discussing here are from chapter 18, section 230, of the Medicare Claims Processing Manual (MCPM), titled Screening for Hepatitis B Virus (HBV).
Initial screening: The section explains that Medicare covers an initial HBV screening for asymptomatic, non-pregnant adolescents and adults at high risk of infection. (For where to find information about coverage for pregnant Medicare patients, keep reading to the end.)
High Risk: Here’s the list of beneficiaries Medicare considers to be high risk for HBV infection:
- People born in a country or region with a high prevalence of HBV infection (2 percent or more)
- U.S.-born people not vaccinated as infants whose parents were born in regions with 8 percent or higher prevalence of HBV
- HIV-positive people
- Men who have sex with men
- Injection drug users
- People with household contact or sexual contact with people with HBV infection.
Repeat screening: Medicare covers repeat screening annually but only for people who have continued high risk (the last three bullet points above) AND who do not receive a hepatitis B vaccination. Keep in mind that annual means “a full 11 months must elapse following the month in which the previous negative screening took place,” per the MCPM.
Coding: Don’t Overlook HCPCS
For Medicare, report the screening for non-pregnant patients using HCPCS code G0499 (Hepatitis B screening in non-pregnant, high risk individual includes hepatitis B surface antigen (HBSAG) followed by a neutralizing confirmatory test for initially reactive results, and antibodies to HBSAG (anti-HBs) and Hepatitis B core antigen (anti-HBc)).
Dx: For coverage of G0499, you need to report both Z11.59 (Encounter for screening for other viral diseases) and Z72.89 (Other problems related to lifestyle).
For rescreening, you must report Z11.59 and one of the high-risk codes below:
- F11.10-F11.99 (Opioid related disorders)
- F13.10-F13.99 (Sedative, hypnotic, or anxiolytic related disorders)
- F14.10-F14.99 (Cocaine related disorders)
- F15.10-F15.99 (Other stimulant related disorders)
- Z20.2 (Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission)
- Z20.5 (Contact with and (suspected) exposure to viral hepatitis)
- Z72.52 (High risk homosexual behavior)
- Z72.53 (High risk bisexual behavior).
ESRD exception: If you report G0499 with ICD-10-CM code N18.6 (End stage renal disease), Medicare covers that, too.
Check Specialty and POS Requirements Before You Code
Medicare covers HBV screening when ordered by one of the following provider specialties:
- 01, General Practice
- 08, Family Practice
- 11, Internal Medicine
- 16, Obstetrics/Gynecology
- 37, Pediatric Medicine
- 38, Geriatric Medicine
- 42, Certified Nurse Midwife
- 50, Nurse Practitioner
- 89, Certified Clinical Nurse Specialist
- 97, Physician Assistant.
The place of service (POS) code needs to match one of these to avoid a denial:
- 11, Physician’s Office
- 19, Off Campus Outpatient Hospital
- 22, On Campus Outpatient Hospital
- 49, Independent Clinic
- 71, State or Local Public Health Clinic
- 81, Independent Laboratory.
The Learning Isn’t Over Yet!
We’ve covered a lot of rules here, but if you code HBV screening, you should check these additional resources, too:
- Read all of MCPM, chapter 18, section 230. We covered the rule for non-pregnant patients, but the section discusses coverage for pregnant patients, as well.
- Check out MCPM, chapter 18, section 170, which also provides information about coding and coverage for HBV screening of pregnant Medicare beneficiaries.
- Shore up your understanding of HBV coverage by reading the National Coverage Determinations (NCDs) for Screening for HBV (210.6), Hepatitis Panel/Acute Hepatitis Panel (190.33), and Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs (210.10).
- Brush up on rules using handy MLN Matters articles like MM9859, Screening for Hepatitis B Virus (HBV) Infection.
- Remember to see what your specific payer has to say. This post covered only Medicare rules.
What About You?
If you code for a lab, do you work with ordering providers to ensure proper coding and documentation of hepatitis B screening? And if you code for an ordering provider, do you work with labs?