First-dollar coverage for preventive services related to HIV Pre-Exposure Prophylaxis (PrEP) medication
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Mandated first-dollar coverage for specified preventive services for members taking HIV PrEP medication who are not infected with HIV, when billed with required screening diagnosis codes and without HIV infection/diagnosis codes.
Allowing up to 4 times per year Hepatitis B and C screening for all those taking PrEP medication and new diagnosis/procedure coding for members with chronic hepatitis allowing up to 2 times per year with procedure code 87517.
STD counseling (G0445) allowed up to 4 times per year for members taking PrEP medication.
Certain kidney function tests (procedure codes 82565, 82575) allowed twice a year for members taking PrEP medication when billed with screening diagnosis codes.
Urine pregnancy test (81025) allowed up to 2 times per year for members taking PrEP medication when billed with screening diagnosis codes.
Adherence counseling (Z71.7 encounters billed with 99401-99404) allowed up to 4 times per year for members taking PrEP medication, but not billable separately if provided during an office visit.
Office visits for related services (99202-99205, 99211-99215) allowed up to 4 times per year for members taking PrEP medication when billed with screening diagnosis codes.
First-dollar coverage extended to HIV PrEP medication for adolescents not infected with HIV and at high risk, with treating physician determining eligibility.
First-dollar Coverage Criteria for PrEP-related Preventive Services
First-dollar coverage criteria for PrEP-related preventive services
Services are covered without member cost-sharing (first-dollar coverage) when billed with HIV screening/exposure diagnosis codes and without HIV infection diagnosis codes (B20 or Z21).
ALL of the following
ALL of the following
- Billed with screening diagnosis Z11.4 or Z20.6; for chronic hepatitis patients also allow Z11.59 and B18.0, B18.1, or B18.2 when applicable
Do not report B20 or Z21 on the same claim
- Procedure codes: 87517 (Hepatitis C antibody test)
For members with chronic hepatitis taking PrEP, 87517 may be billed up to 2 times per year when billed with the chronic hepatitis diagnosis codes without Z21 or B20
- Up to 4 times per year for members taking PrEP medication; for chronic hepatitis patients 87517 up to 2 times per year
- First-dollar coverage (no member cost-sharing) when coding rules met
ALL of the following
- Billed with Z11.4 or Z20.6 without B20 or Z21
- Up to 4 times per year for members taking PrEP medication
- First-dollar coverage when coding rules met
ALL of the following
- Billed with Z11.4 or Z20.6 without B20 or Z21
- Allowed twice per year for each procedure code for members taking PrEP medication
- First-dollar coverage when coding rules met
ALL of the following
- Billed with Z11.4 or Z20.6 without B20 or Z21
- Up to 2 times per year for members taking PrEP medication
- First-dollar coverage when coding rules met
ALL of the following
- Z71.7 for HIV counseling without B20 or Z21
- 99401-99404
- Up to 4 times per year for members taking PrEP medication
- Do not bill 99401-99404 separately if adherence counseling is provided during an allowed office visit (see next node); deny 99401-99404 when billed in the same office visit as 99202-99205 or 99211-99215
- First-dollar coverage when coding rules met
ALL of the following
- Z11.4 or Z20.6 without B20 or Z21
- 99202-99205, 99211-99215
- Up to 4 times per year for members taking PrEP medication
- If adherence counseling is performed during the office visit, do not bill 99401-99404 separately (the office visit includes adherence counseling).
- First-dollar coverage when coding rules met
ALL of the following
- Adolescent must not be infected with HIV and must be at high risk of HIV infection
- Treating physician determines adolescent eligibility
- First-dollar coverage for eligible adolescents
Diagnosis and Procedure Codes; Frequencies
| Z11.4 | Encounter for screening for HIV |
| Z20.6 | Contact with and (suspected) exposure to HIV |
| B20 | HIV disease |
| Z21 | Asymptomatic HIV infection status |
| Z11.59 | Other screening for infectious and parasitic diseases (listed as Z1159) |
| B18.0 | Chronic viral hepatitis B with delta-agent |
| B18.1 | Chronic viral hepatitis B without delta-agent |
| B18.2 | Chronic viral hepatitis C |
| 87517 | Hepatitis C antibody test (procedure code referenced for chronic hepatitis patients) |
| G0445 | STD counseling |
| 82565 | Creatinine; other or unspecified method |
| 82575 | Creatinine; ion-selective electrode (ISE) |
| 81025 | Urine pregnancy test, by dipstick or tablet reagent; non-automated |
| 99401 | Preventive medicine counseling, 15 minutes (adherence counseling range 99401-99404 referenced) |
| 99402 | Preventive medicine counseling, 30 minutes (adherence counseling range 99401-99404 referenced) |
| 99403 | Preventive medicine counseling, 45 minutes (adherence counseling range 99401-99404 referenced) |
| 99404 | Preventive medicine counseling, 60 minutes (adherence counseling range 99401-99404 referenced) |
| 99202 | Office or other outpatient visit, new patient, typically 20 minutes (office visit range 99202-99205 referenced) |
Billing, Claim Submission, and Documentation Guidance
Billing and claim submission requirements and denial risks for PrEP preventive services
Bill all listed preventive procedure codes with a screening diagnosis of Z11.4 (encounter for screening for HIV) or Z20.6 (contact with and suspected exposure to HIV) and do not report HIV infection/diagnosis codes B20 or Z21 on the same claim to receive first-dollar coverage for PrEP-related preventive services. Adherence counseling codes (99401–99404) must not be billed separately if provided during the same office visit (99202–99205 or 99211–99215); when billed in the same visit, the 99401–99404 codes will be denied because adherence counseling is included in the office visit. For members with chronic hepatitis taking PrEP, include diagnosis Z11.59 or B18.0/B18.1/B18.2 with procedure 87517 as specified and observe the reduced frequency limit for that procedure.
- Required diagnosis linkage for first-dollar coverage: Z11.4 or Z20.6 without B20 or Z21.
- Do not bill 99401–99404 separately when an office visit (99202–99205 or 99211–99215) is billed in the same encounter; 99401–99404 will be denied in that circumstance.
- Chronic hepatitis patients: use Z11.59 and B18.0/B18.1/B18.2 with procedure 87517 as applicable and note 87517 is allowed up to 2 times per year for chronic hepatitis members taking PrEP.
- General frequency limits to observe when submitting claims: hepatitis B/C screening up to 4x/year; STD counseling (G0445) up to 4x/year; kidney function tests (82565, 82575) up to 2x/year per procedure; urine pregnancy test (81025) up to 2x/year; adherence counseling/office visits up to 4x/year.
Key Definitions
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