Summary & Overview

HCPCS G0013: Individual PrEP Counseling and HIV Risk Assessment

HCPCS Level II code G0013 represents individual counseling by clinical staff for pre-exposure prophylaxis (PrEP) aimed at preventing human immunodeficiency virus (HIV). The code covers HIV risk assessment (initial and ongoing), targeted risk-reduction counseling, and medication adherence support—services that are central to HIV prevention efforts and to maximizing the effectiveness of PrEP at the population level. National attention on PrEP uptake and retention makes billing clarity for these counseling services important for clinics and payers.

Key payers in the analysis include Aetna, Blue Cross Blue Shield plans, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise description of the clinical service represented by G0013, an overview of typical care settings, and the common modifiers associated with billing this service. The publication summarizes payer coverage patterns and benchmarking context where available and highlights policy and coding considerations that affect reimbursement and program implementation. The content provides clinicians, billing staff, and policy analysts with the operational context needed to identify when G0013 applies, how it aligns with preventive care for HIV, and what documentation elements are commonly relevant. Data not available in the input will be noted as such in the detailed sections.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG0013HCPCS Level IIPrEP counselingHIV preventionrisk assessmentmedication adherenceoutpatient servicesbehavioral counseling

Billing Code Overview

HCPCS Level II code G0013 describes individual counseling for pre-exposure prophylaxis (PrEP) provided by clinical staff to prevent human immunodeficiency virus (HIV). The service includes HIV risk assessment (initial or continued assessment of risk), HIV risk reduction counseling, and medication adherence counseling related to PrEP.

Service type: Preventive behavioral counseling and adherence support for PrEP

Typical site of service: Outpatient clinical settings, including primary care clinics, sexual health clinics, community health centers, and other ambulatory care locations where clinical staff provide one-on-one counseling for HIV prevention and PrEP adherence.

Clinical & Coding Specifications

Clinical Context

A 28-year-old cisgender man presents to a community sexual health clinic requesting pre-exposure prophylaxis (PrEP) for HIV prevention after reporting multiple condomless receptive anal sex encounters with partners of unknown HIV status. Clinical staff (licensed practical nurse or certified medical assistant under standing order) perform an initial HIV risk assessment, review adherence considerations, counsel on risk-reduction strategies, and provide medication counseling for daily oral PrEP. The workflow includes: patient registration and consent, brief behavioral and exposure history, baseline rapid or laboratory HIV testing and screening for hepatitis B, creatinine, and sexually transmitted infections as per clinic protocol (may be ordered by clinician), delivery of individualized adherence counseling and risk-reduction education using shared decision-making, documentation of topics covered and time spent, and scheduling of follow-up visits (typically at 1 month then every 3 months). Billing for G0013 is used for the individual counseling session by clinical staff focused on HIV risk assessment, risk reduction, and medication adherence. Typical sites of service include outpatient clinics, community health centers, sexual health clinics, and federally qualified health centers where clinical staff operate under provider protocol. A typical scenario for continued assessment involves a patient on PrEP returning for a counseling visit between laboratory follow-ups to address adherence barriers, side effects, and ongoing risk behaviors.

Coding Specifications

Modifier	Description	When to Use
`95`	Synchronous telemedicine service rendered via real-time interactive audio and video	Use when the counseling session for PrEP is delivered through live audiovisual telehealth and payer accepts modifier `95`.
`GQ`	Telehealth via asynchronous telecommunications system	Use when a store-and-forward encounter meets payer rules for asynchronous telemedicine billing.
`GT`	Via interactive audio and video telecommunications system (telehealth)	Use when the encounter is provided by telehealth via interactive audio-video and payer requires `GT` instead of `95`.
`25`	Significant, separately identifiable E/M service by the same physician on the same day (Note: not in provided list; omitted)	Data not available in the input.
`52`	Reduced services	Use when the counseling encounter is partially furnished or abbreviated and full service elements are not completed.
`53`	Discontinued procedure	Use when the counseling session is started but discontinued due to patient intolerance or emergency.
`59`	Distinct procedural service (Note: not in provided list; omitted)	Data not available in the input.
`22`	Increased procedural services	Use when counseling required substantially greater work or time than typically required for `G0013` and documentation supports increased complexity.
`23`	Unusual anesthesia (Note: rarely applicable)	Generally not applicable but may be present in the modifier list; not typically used for `G0013`.
`95`	(duplicate entry removed)	Duplicate entries avoided.
`CQ`	Service furnished by a rehabilitation agency which is certified	Use only when applicable per payer rules; rarely applicable to PrEP counseling.
`QK`	Medical direction of two, three or four separately identifiable physician-anesthesiologists (Note: not applicable)	Not applicable to `G0013`.
`QX`	Service furnished by a qualified nonphysician practitioner with modifier attestation	Use when required to indicate a qualified nonphysician practitioner performed the counseling under appropriate supervision.
`QY`	Medical direction of one certified registered nurse anesthetist by an anesthesiologist (Note: not applicable)	Not applicable to `G0013`.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians and their staff commonly provide PrEP counseling in outpatient settings.
`207R00000X`	Internal Medicine	Internal medicine clinicians and clinic staff provide risk assessment and adherence counseling for PrEP.
`261QP2400X`	Infectious Disease	Infectious disease specialists oversee PrEP programs and complex cases; staff may provide counseling.
`2084P0800X`	Preventive Medicine	Preventive medicine clinicians and staff may lead clinic-based HIV prevention services.
`335E00000X`	HIV/AIDS Specialist	Specialized HIV care programs and staff provide targeted PrEP counseling and follow-up.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z11.4`	Encounter for screening for human immunodeficiency virus [HIV]	Used when the visit includes HIV screening in the context of PrEP risk assessment.
`Z20.2`	Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission	Documents exposure risk that supports PrEP counseling.
`Z72.51`	High-risk sexual behavior	Captures behavioral risk factors discussed during PrEP counseling.
`Z21`	Asymptomatic human immunodeficiency virus [HIV] infection status	Relevant when documenting HIV-negative status history for patients engaged in prevention services; used cautiously.
`R63.5`	Abnormal weight gain (Note: example comorbidity)	May be used if medication side effects or adherence factors are discussed; ancillary relevance.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Commonly billed by clinicians for the medical evaluation that accompanies PrEP initiation or follow-up; `G0013` covers the individual counseling by clinical staff in addition to clinician E/M when appropriately documented.
`99406`	Smoking and tobacco use cessation counseling, intermediate, 3-10 minutes (Note: analogous counseling CPT)	Behavioral counseling codes like `99406` are conceptually similar; not specific to PrEP but sometimes used for separate tobacco cessation counseling during the same visit.
`87800`	Infectious agent antigen detection by immunoassay technique, qualitative or semi-quantitative (Note: example for rapid HIV test)	Rapid HIV tests or other point-of-care tests are performed alongside counseling; billed separately when appropriate.
`80053`	Comprehensive metabolic panel	Baseline and periodic laboratory monitoring for patients on PrEP, including creatinine, are commonly ordered and billed separately.
`87389`	HIV-1/2 antigen/antibody immunoassay	Laboratory testing for HIV status is directly related to safe provision of PrEP and billed separately.