Clinical Context
A 32-year-old patient presents to an outpatient primary care clinic requesting screening for hepatitis C after disclosing a history of injection drug use and prior incarceration. The clinician reviews risk factors, documents indications for testing, and orders a hepatitis C antibody screen. The specimen is collected via venipuncture in the clinic or a nearby lab. The test is performed by the laboratory; if reactive, reflex confirmatory RNA testing is ordered or the patient is referred for follow-up care and counseling. Documentation includes rationale for screening (high-risk behavior), informed consent, specimen source, and any payer-required screening indication. Typical workflow steps: patient intake and risk assessment, clinician order for G0472, specimen collection, lab processing and result reporting, and follow-up communication for reactive or non-reactive results.
Coding Specifications
| Modifier | Description | When to Use |
|---|
00 | Default (no modifier) | Use when no modifier applies and reporting the service as billed. |
11 | Professional component | Use when reporting only the professional component of a separately payable lab service (rare for waived antibody screens; include if applicable).
26 | Professional component | Use when billing only the professional component of a test that has a split technical/professional component.
52 | Reduced services | Use when the service is partially reduced or not fully performed compared with standard procedure.
53 | Discontinued procedure | Use when specimen collection or testing was started but discontinued for patient safety or other reasons.
59 | Distinct procedural service | Use when the screening service is distinct and separate from other services on the same day.
90 | Reference (outside) laboratory | Use when the test was performed by an outside independent laboratory and billed through the ordering provider.
AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | Rarely applicable; include only if specific payer requires this modifier in ancillary roles.
GA | Waiver of liability statement on file (patient refuses or cannot pay) | Use when an ABN or similar waiver is on file and payer requires this modifier for non-covered services.
GZ | Item or service expected to be denied as not reasonable and necessary | Use when billing anticipates denial and no waiver exists.
| Taxonomy Code | Specialty | Notes |
|---|
207Q00000X | Family Medicine | Primary care clinicians who commonly order screening tests including hepatitis C antibody. |
207R00000X | Internal Medicine | Internists conducting preventive care and risk-based infectious disease screening.
363LF0000X | Clinical Laboratory | Laboratories performing the hepatitis C antibody assay and confirmatory testing.
208000000X | Emergency Medicine | Emergency clinicians may order screening for high-risk patients presenting to ED.
333600000X | Infectious Disease | Specialists involved when screening is positive and confirmatory testing or treatment planning is required.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
Z72.0 | Tobacco use | Tobacco use can be assessed during screening visits; often documented in preventive care. |
F11.20 | Opioid dependence, uncomplicated | Injection drug use or opioid dependence are key risk factors prompting hepatitis C antibody screening.
Z20.2 | Contact with and (suspected) exposure to infections with a predominantly blood-borne route of transmission | Used when there is known exposure risk to blood-borne pathogens prompting screening.
Z98.890 | Other specified postprocedural states | May be used when prior procedures (e.g., transfusions abroad) increase screening indication.
Z72.51 | High-risk sexual behavior | High-risk sexual behavior is an indication for hepatitis C screening in some guidelines.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
36415 | Collection of venous blood by venipuncture | Used to obtain the specimen for the hepatitis C antibody screen when blood draw is performed at the point of care. |
80061 | Lipid panel (cholesterol, HDL, triglycerides) | Often ordered during preventive health visits alongside infectious disease screening in primary care workflows.
87491 | Infectious agent detection by nucleic acid (e.g., hepatitis C virus), qualitative, for RNA, single step (e.g., RT-PCR), direct probe; quantitative or qualitative | Performed as confirmatory testing for a reactive hepatitis C antibody screen to detect HCV RNA.
82550 | Blood, hepatitis C; antibody (EIA) | Alternative CPT-level code for hepatitis C antibody testing that may be used by some laboratories when reporting at CPT rather than HCPCS level.
99406 | Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes | Counseling codes that may be billed during the same visit for risk reduction and behavioral counseling when high-risk behaviors are identified.