Summary & Overview
HCPCS G0475: HIV Antigen/Antibody Combination Assay, Screening
HCPCS Level II code G0475 designates an HIV antigen/antibody combination assay used for screening individuals for HIV infection. This laboratory screening code is important for public health and preventive care, as combined antigen/antibody tests increase early detection of HIV compared with antibody-only tests. Nationally, such screening supports timely linkage to care and reduces transmission through earlier diagnosis.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of coverage considerations, common billing modifiers, and where the service is typically furnished. The publication outlines typical reimbursement benchmarking elements, coding and billing context for laboratory screening services, and potential policy updates affecting coverage and payment for combination HIV assays.
This summary equips clinicians, billing professionals, and policy analysts with the clinical context, payer landscape, and coding fundamentals relevant to G0475. Data not available in the input will be noted where applicable in detailed sections.
Billing Code Overview
HCPCS Level II code G0475 represents an HIV antigen/antibody combination assay used for screening patients for HIV infection. This code describes a laboratory assay that detects both HIV antigen and HIV antibodies in a single combined test.
Service Type: Laboratory screening assay
Typical Site of Service: Clinical laboratory or outpatient facility
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Clinical & Coding Specifications
Clinical Context
A 28-year-old sexually active adult presents to a primary care clinic for routine preventive care and requests HIV screening. The clinician documents routine screening and sexual history that indicates no known HIV exposure but notes recent new sexual partners and inconsistent condom use. The clinical workflow begins with registration verifying insurance and consent for HIV testing, collection of demographic and risk information, and point-of-care or laboratory blood draw for the G0475 HIV antigen/antibody combination assay. The specimen is labeled, sent to the laboratory, and tested using a fourth-generation antigen/antibody platform. Negative results are reported to the patient by phone or portal; reactive or indeterminate results trigger reflex confirmatory testing per public health guidance and linkage to care workflows, including counseling and referral to infectious disease or HIV care. Typical site of service is an outpatient clinic, community health center, sexually transmitted infection clinic, or laboratory collection site. The typical patient scenario includes asymptomatic individuals presenting for routine screening, pregnant patients at initial prenatal visit or third-trimester rescreening, persons with potential occupational or non-occupational exposure, or patients presenting with symptoms suggestive of acute HIV infection who require combination antigen/antibody testing.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure |