Human Immunodeficiency Virus (HIV)
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Defines BCBSNM lab reimbursement criteria for screening, confirmatory, viral load, genotyping/phenotyping, and related HIV tests; applies to providers submitting claims to Blue Cross Blue Shield - New Mexico.
Screening for HIV-1 and HIV-2 using an antibody test that does not provide rapid results and does not incorporate antigen testing is not reimbursable.
Code 86689 was removed from the procedure code list.
Notes and frequency language revised to reference Note 1 for repeat antibody/antigen testing and Note 3 for RNA quantification baseline considerations.
Added Notes 1 and 2 and new items addressing PrEP-related screening and testing.
Reimbursement and Coverage Criteria
Extracted reimbursement criteria (summary)
Reimbursable tests and clinical situations where testing may be covered include the following:
ALL of the following
Screening
- Initial screening for HIV infection with an antigen/antibody combination assay for individuals 11 to 65 years of age
- Repeat antigen/antibody screening for individuals 11 to 65 years of age (see Note 1)
- Screening with an antigen/antibody combination assay or a rapid antibody test for individuals who will begin pre-exposure prophylaxis (PrEP), who are receiving PrEP, or who have elevated risk factors (see Note 2)
Post-screening confirmation
- HIV-1/HIV-2 antibody differentiation assay for individuals with a positive initial screening (see Note 1)
- Nucleic acid testing (qualitative or quantitative) for individuals with initial positive or indeterminate screening, or when recent exposure is suspected or reported
Genotype / Phenotype and Viral Load
- HIV genotyping or phenotyping prior to initiating doravirine therapy (genotyping and phenotyping required)
- HIV genotyping or phenotyping for individuals who have failed a course of antiviral therapy, have suboptimal viral load reduction, or are noncompliant with therapy
- Genotyping or phenotyping to guide treatment in acute or recent infection (within the last 6 months), for antiretroviral-naïve individuals entering treatment, and for pregnant individuals before initiation of antiretroviral therapy or with detectable HIV RNA loads
- HIV phenotyping may be reimbursable for treatment-experienced individuals on failing regimens who are thought to have multidrug resistance
- Plasma quantification of HIV-1 or HIV-2 RNA for monitoring disease progression, monitoring response to antiretroviral therapy, infants younger than 18 months born to HIV-positive mothers, and predicting maternal-fetal transmission (see Notes 1 & 3)
Procedure Codes, Frequency Limits, and Notes
| 86701 | HIV-1ANTIBODY |
| 86702 | HIV-2 ANTIBODY |
| 86703 | HIV-1/HIV-2 1 RESULT ANTBDY |
| 87389 | HIV-1 AG W/HIV-1&-2 AB AG IA |
| 87390 | HIV-1 AG IA |
| 87391 | HIV-2 AG IA |
| 87534 | HIV-1 DNA DIR PROBE |
| 87535 | HIV-1 PROBE&REVERSE TRNSCRPJ |
| 87536 | HIV-1 QUANT&REVRSE TRNSCRPJ |
| 87537 | HIV-2 DNA DIR PROBE |
| 86689 | CPT code removed from policy (no longer reimbursable per history). |
Claims Submission, Documentation, and Billing Implications
Claims submission, documentation, and claim‑review risk
Providers must submit accurate documentation of services rendered and use valid HIPAA‑approved code combinations when billing for HIV testing. Claims are subject to code‑edit protocols and may be reviewed against Plan documents, provider contracts, medical policies, reimbursement policies, and coding software logic; upon request providers should supply additional documentation to support the claim.
- Submit claims using valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, etc.).
- Code claims according to industry standard coding guidelines (Uniform Billing Editor, AMA CPT Assistant, CMS NCCI, CCI edits).
- Be prepared for claim review and to provide additional documentation upon request; Plan documents or provider contracts govern if conflicts arise.
Reimbursement and billing updates (policy history changes)
Review the policy history and update billing practices to reflect recent reimbursement changes: an explicit non‑reimbursement of antibody‑only screening tests (added item #9) and the removal of CPT code 86689 from the procedure code list. Frequency language for repeat testing was also revised and now references policy Notes for antibody/antigen and nucleic acid testing intervals.
- Do not bill for screening that uses an antibody test that does not provide rapid results and does not incorporate antigen testing (added as item #9).
- Remove CPT code 86689 from billing submissions — this code was removed from the policy.
- Note changes to repeat‑test frequency wording (e.g., antibody/antigen and NAT intervals) and follow the Notes referenced in the policy when determining allowable testing intervals.
Test Definitions and Assay Types
Policy Revisions and Effective Dates
Added item #9 excluding reimbursement for antibody-only HIV screening tests that do not provide rapid results and do not incorporate antigen testing; removed CPT code 86689; references revised.
Revised reimbursement information: removed specific 'no more than one test every 90 days' wording from item #2 and referenced Note 1; added items addressing PrEP-related screening and antibody differentiation reimbursement; adjusted monthly test language and added Notes 1 and 2; clarified antigen-only non-reimbursement.
Added antigen/antibody combination assay language to initial screening and reinstated 'no more than one test every 90 days' wording for repeat testing; added nucleic acid testing allowance (no more than one test every month) for specific situations; removed item #6.
Document updated with literature review (edits to reimbursement information noted in history).
Reimbursement information revised for clarity; added items regarding HIV genotyping and phenotyping and updated references and title.
Policy created (new policy established for plasma HIV-1 and HIV-2 RNA quantification and related reimbursement criteria).
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