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New HCPCS code G0445 to cover Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs


Effective for dates of service on or after November 8, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover
screening for Sexually Transmitted Infections (STIs) - specifically chlamydia, gonorrhea, syphilis, and hepatitis B - with the appropriate Food and Drug Administration (FDA) approved/cleared laboratory tests when ordered by the primary care provider. The tests must be used consistent with FDA approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations and performed by an eligible Medicare provider for these services.

In addition, Medicare will cover High Intensity Behavioral Counseling (HIBC) to prevent STIs. Ensure that your billing staffs are aware of these changes.

HCPCS / CPT information

A new Healthcare Common Procedure Coding System (HCPCS) code, G0445 (high-intensity behavioral counseling to prevent sexually transmitted infections, face-to-face, individual, includes: education, skills training, and guidance on how to change sexual behavior, performed semi-annually, 30 minutes), has been created for use when reporting HIBC to prevent STIs, effective November 8, 2011. This code is included in the January 2012 Medicare Physician Fee Schedule Database (MPFSDB) and Integrated Outpatient Code Editor (IOCE) updates.

ICD 9 CM information

The appropriate screening diagnosis code (ICD-9-CM V74.5 (screening bacterial – sexually transmitted) or V73.89 (screening, disease or disorder, viral, specified type NEC)), when used with the screening lab tests identified by Change Request (CR) 7610, will indicate that the test is a screening test covered by Medicare.

Diagnosis code V69.8 (other problems related to life style) is used to indicate that the beneficiary is at high/increased risk for STIs. Providers should also use V69.8 for sexually active adolescents when billing G0445 counseling services.

Diagnosis codes V22.0 (supervision of normal first pregnancy), V22.1 (supervision of other normal pregnancy), or V23.9 (supervision of unspecified high-risk pregnancy) are also to be used when appropriate.

Specialty Types

Effective for dates of service on or after November 8, 2011, contractors shall allow screenings for chlamydia, gonorrhea, and syphilis when reported with ICD-9 code V74.5; and/or hepatitis B when reported with ICD-9 code V73.89, only when ordered by a primary care practitioner (physician or non-physician) with any of the following specialty codes on the provider’s enrollment record:

01 – General Practice

08 – Family Practice

11 – Internal Medicine

16 – Obstetrics/Gynecology

37 – Pediatric Medicine

38 – Geriatric Medicine

42 – Certified Nurse Midwife

50 – Nurse Practitioner

89 – Certified Clinical Nurse Specialist

97 – Physician Assistant

Place of Service

Contractors shall pay claims for HCPCS G0445 only when services are provided for the following place of service (POS):

11- Physician’s Office

22 - Outpatient Hospital

49 - Independent Clinic

71- State or local public health clinic

Type of Service

The type of service (TOS) for HCPCS code G0445 is 1.

Coverage Limitations

This code may be paid on the same date of service as an annual wellness visit (AWV), evaluation and management (E&M) code, or during the global billing period for obstetrical care, but only one G0445 may be paid on any one date of service.

If billed on the same date of service with an E&M code, the E&M code should have a distinct diagnosis code other than the diagnosis code used to indicate high/increased risk for STIs for the G0445 service.

An E&M code should not be billed when the sole reason for the visit is HIBC to prevent STIs.

Contractors shall deny claims for HCPCS G0445 that are submitted without V69.8. The use of the correct diagnosis code(s) on the claims is imperative to identify these services as preventive services and to show that the services were provided within the guidelines for coverage as preventive services. The patient’s medical record must clearly support the diagnosis of high/increased risk for STIs and clearly reflect the components of the HIBC service provided – education, skills training, and guidance on how to change sexual behavior - as required for coverage.

For services provided on an annual basis, this is defined as a 12-month period.

Deductible and Coinsurance

Effective for dates of service on and after November 8, 2011, deductible and coinsurance do not apply to claim lines with G0445.

Reference: http://www.cms.gov/MLNMattersArticles/downloads/MM7610.pdf

Also see Complete list of Screening codes effective for the year 2012

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