G9245 Antiretroviral Therapy Reimbursement | OpenPayer

Summary & Overview

HCPCS G9245: Antiretroviral Therapy Prescribed

HCPCS Level II code G9245 denotes the prescription of antiretroviral therapy for patients with HIV. Nationally relevant as antiretroviral medications are central to HIV care, this code captures the clinical act of prescribing and initiating or managing antiretroviral regimens. Accurate use supports clinical documentation, care coordination, and claims processing for outpatient HIV management.

Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical context for the code, common service settings, and the types of benchmarks and policy and billing considerations typically covered in billing-code level briefs. This includes reimbursement benchmarking, coding guidance, and the relationship of the code to outpatient treatment workflows.

The publication provides a concise reference for billing staff, practice managers, and policy analysts seeking to understand how G9245 is used in claims, what settings it applies to, and which national payers commonly encounter the code. Data elements that were not provided in the input—such as specific modifiers, associated taxonomies, typical ICD-10 pairings, and payer-specific payment rates—are noted as not available where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9245HCPCS Level IIantiretroviral therapyHIV treatmentoutpatient servicesprescription managementbilling guidanceclaims coding

Billing Code Overview

HCPCS Level II code G9245 represents antiretroviral therapy prescribed. This code describes the provision or prescription of antiretroviral medications used in the treatment of human immunodeficiency virus (HIV) infection.

Service type: Prescription and management of antiretroviral therapy
Typical site of service: Outpatient clinic or ambulatory care setting where clinicians prescribe and manage long-term HIV medications

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult newly diagnosed with HIV infection or an existing patient with documented virologic failure, drug resistance, or intolerance to current medications who is prescribed antiretroviral therapy. The clinical workflow begins with an HIV specialist, infectious disease clinician, or primary care provider performing a baseline evaluation including history, physical exam, baseline laboratory testing (HIV viral load, CD4 count, hepatitis B and C serologies, renal and hepatic function, and relevant resistance testing). Following review of laboratory results and medication history, the clinician selects an appropriate antiretroviral regimen, issues a prescription, counsels the patient on adherence and adverse effects, and documents the plan in the medical record. Follow-up visits occur within 2–8 weeks to assess tolerance and adherence, repeat viral load and safety labs as indicated, and adjust therapy if necessary. Typical sites of service include outpatient clinic, HIV specialty clinic, Federally Qualified Health Center, and community health centers where antiretroviral initiation and management are routinely provided.

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure	Use when an E/M visit is performed and documented as separately identifiable from the prescription/medication management encounter on the same day.

HCPCS G8494: Completion of Diabetes Mellitus Quality Actions

HCPCS-G9203-HEPATITIS-C-RNA-TESTING-PRE-TREATMENT

HCPCS G9203: Hepatitis C RNA Testing Documented Within 12 Months

HCPCS-G9921-INCOMPLETE-OR-NO-SCREENING-DOCUMENTED

HCPCS G9921: No or Partial Screening, Positive Screen without Recommendations

HCPCS-LEVEL-II-G2158-PNEUMOCOCCAL-VACCINE-ADVERSE-REACTION-HISTORY

HCPCS Level II G2158: Prior Pneumococcal Vaccine Adverse Reaction

HCPCS-G2108-INSTITUTIONAL-SNP-LONG-TERM-CARE-RESIDENCY-90-DAYS

HCPCS G2108: Institutional SNP or Long-Term Care Residency >90 Days

HCPCS-G9112-HEAD-AND-NECK-CANCER-STAGING-UNKNOWN

HCPCS G9112: Head and Neck Cancer, Staging Unknown

HCPCS-G8464-PROSTATE-CANCER-NOT-ELIGIBLE-FOR-ADJUVANT-HORMONAL-THERAPY

HCPCS G8464: Prostate Cancer—Not Eligible for Adjuvant Hormonal Therapy

HCPCS-G9912-HBV-ASSESSMENT-BEFORE-ANTI-TNF-THERAPY

HCPCS G9912: Hepatitis B Assessment and Interpretation Before Anti-TNF Therapy

HCPCS-G8891-LDL-C-NOT-UNDER-CONTROL-DOCUMENTATION

HCPCS G8891: Documentation of LDL-C Not Under Control

HCPCS-G9610-NOT-ORDERING-ANTIPLATELET-AGENTS-MEDICAL-REASON-DOCUMENTATION

HCPCS G9610: Documentation of Reason for Not Ordering Anti-Platelet Agents

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`207Q00000X`	Infectious Disease	Specialists who initiate and manage complex antiretroviral regimens.
`208000000X`	Internal Medicine	Primary care physicians who manage HIV care and antiretroviral prescribing.
`208D00000X`	Family Medicine	Family physicians providing longitudinal HIV care and medication management.
`363L00000X`	Nurse Practitioner	Nurse practitioners who prescribe and manage antiretroviral therapy in outpatient settings.
`363A00000X`	Physician Assistant	Physician assistants who participate in prescribing and follow-up for antiretroviral therapy.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`B20`	Human immunodeficiency virus [HIV] disease	Primary diagnosis indicating HIV infection necessitating antiretroviral therapy.
`Z21`	Asymptomatic human immunodeficiency virus [HIV] infection status	Used when a patient is HIV-positive without symptoms and may require treatment initiation or monitoring.
`R75`	Inconclusive laboratory evidence of human immunodeficiency virus [HIV]	May trigger follow-up testing and potential initiation of antiretroviral therapy after confirmation.
`Z11.4`	Encounter for screening for human immunodeficiency virus [HIV]	Screening visits that can lead to diagnosis and subsequent antiretroviral prescription.
`D73.3`	Splenic sequestration (not commonly associated; placeholder)	Data not available in the input.
`Z90.79`	Acquired absence of other specified organs and tissue (not directly related)	Data not available in the input.

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	Common outpatient E/M visit used for medication management, adherence counseling, and follow-up after initiating or adjusting antiretroviral therapy.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used for more complex medication management visits involving multiple comorbidities, regimen changes, or significant counseling regarding antiretroviral therapy.
`36415`	Collection of venous blood by venipuncture	Performed to obtain baseline and monitoring laboratory specimens such as viral load, CD4 count, and safety labs before or after initiating antiretroviral therapy.
`87804`	Infectious agent antigen detection by immunoassay with direct optical observation; HIV-1/2 antigen/antibody	Used for HIV screening/diagnosis which precedes initiation of antiretroviral therapy.
`87535`	Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique	Used for HIV viral load testing to guide antiretroviral therapy decisions and monitor response.
`99499`	Unlisted evaluation and management service	Occasionally used for novel or atypical telehealth or care coordination services related to antiretroviral therapy when no specific code exists.

OpenPayer