Coverage Policy Manual
Policy #: 2011040
Category: PPACA Preventive
Initiated: September 2010
Last Review: April 2024
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: HUMAN IMMUNODEFICIENCY VIRUS (HIV) COUNSELING and SCREENING
Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
An additional component of the law was a requirement that all “non-grandfathered” health insurance plans, effective  August 1, 2012, are required to provide coverage without cost sharing consistent with the Health Resources and Services Administration ‘s (HRSA’s) Women's Preventive Services: Required Health Plan Coverage Guidelines. The HRSA-supported health plan coverage guidelines were developed by the Department of Health and Human Services (HHS) commissioned Institute of Medicine (IOM). HHS commissioned an IOM study to review what preventive services are necessary for women’s health and well-being and should be considered in the development of comprehensive guidelines for preventive services for women.  HRSA supports the IOM’s recommendations on preventive services that address health needs specific to women and fill gaps in existing guidelines.
 
Policy/
Coverage:
Effective December 2023
 
Screening for HIV is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) up to four times per year for the following:
 
    • All adolescents and adults aged 15 to 65 years of age;
    • Younger adolescents and older adults who are at increased risk for HIV infection (risk factor discussion below);  
    • For all pregnant women (including those who present in labor who are untested and whose HIV status is unknown);
    • All sexually active women  
 
The appropriate ICD-10 codes to report these services are O09-O09.40, O09.519, O09.529-O09.93, Z00.00-Z00.01, Z11.4, Z20.2, Z20.6, Z33.1, Z34.00-Z34.93, Z71.7, Z72.51-Z72.53 or Z72.89.
 
Codes that may be used to report these services include 86689, 86701, 86703, 87389, 87390, 87535, 87806, 99401, 99402, 99403, 99404, G0432, G0433, G0435 or S3645.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
 
Effective October 2013 through November 2023
 
Screening for HIV is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) up to three times per year for the following:
 
    • All adolescents and adults aged 15 to 65 years of age;
    • Younger adolescents and older adults who are at increased risk for HIV infection (risk factor discussion below);
    • For all pregnant women (including those who present in labor who are untested and whose HIV status is unknown);
    • All sexually active women.
 
The appropriate ICD-10 codes to report these services are O09-O09.40, O09.519, O09.529-O09.93, Z00.00-Z00.01, Z11.4, Z20.2, Z20.6, Z33.1, Z34.00-Z34.93, Z71.7, Z72.51-Z72.53 or Z72.89.
 
Codes that may be used to report these services include 86689, 86701, 86703, 87389, 87390, 87535, 87806, 99401, 99402, 99403, 99404, G0432, G0433, G0435 or S3645.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
 
Effective prior to October 2013
Screening for HIV is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay)
    • For all adolescents and adults at increased risk for HIV infection (risk factor discussion below); maybe billed twice yearly.
    • For all pregnant women   
 
The appropriate ICD-9 code to report these services is V01.79, V22.0, V22.1, V22.2, V23.0-V23.9, V69.2, V69.8 or V73.89.
 
Codes that may be used to report these services include 86689, 86701,  86703, 87390, 87535,  G0432, G0433, G0435 or S3645.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
Rationale:
    • The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection.  (A Recommendation)
The USPSTF found good evidence that both standard and U.S. Food and Drug Administration (FDA)-approved rapid screening tests accurately detect HIV infection. The USPSTF also found good evidence that appropriately timed interventions, particularly highly active antiretroviral therapy (HAART), lead to improved health outcomes for many of those screened, including reduced risk for clinical progression and reduced mortality. Since false-positive test results are rare, harms associated with HIV screening are minimal. Potential harms of true-positive test results include increased anxiety, labeling, and effects on close relationships. Most adverse events associated with HAART, including metabolic disturbances associated with an increased risk for cardiovascular events, may be ameliorated by changes in regimen or appropriate treatment. The USPSTF concluded that the benefits of screening individuals at increased risk substantially outweigh potential harms.
 
    • The USPSTF makes no recommendation for or against routinely screening for HIV adolescents and adults who are not at increased risk for HIV infection.  (C Recommendation.)
Rationale: The USPSTF found fair evidence that screening adolescents and adults not known to be at increased risk for HIV can detect additional individuals with HIV, and good evidence that appropriately timed interventions, especially HAART, lead to improved health outcomes for some of these individuals. However, the yield of screening persons without risk factors would be low, and potential harms associated with screening have been noted (above). The USPSTF concluded that the benefit of screening adolescents and adults without risk factors for HIV is too small relative to potential harms to justify a general recommendation.
 
In September 2006, the Centers for Disease Control and Prevention (CDC) published revised guidelines recommending that all individuals between 13 and 64 yeas of age be screened for HIV regardless of recognized risk factors (1). In making this recommendation, the CDC considered a number of factors, including research published subsequent to the completion of the systematic evidence report on which the 2005 HIV screening recommendations of the USPSTF are based.
In November 2006, the USPSTF assessed this new research using established methods for evaluating the quality and strength of the evidence (2). Based on this review (3), the USPSTF confirmed its "C" recommendation for screening non-pregnant adolescents and adults who are not at increased risk for HIV infection.
 
    • The USPSTF recommends that clinicians screen all pregnant women for HIV.  (A Recommendation)
The USPSTF found good evidence that both standard and FDA-approved rapid screening tests accurately detect HIV infection in pregnant women and fair evidence that introduction of universal prenatal counseling and voluntary testing increases the proportion of HIV-infected women who are diagnosed and are treated before delivery. There is good evidence that recommended regimens of HAART are acceptable to pregnant women and lead to significantly reduced rates of mother-to-child transmission. Early detection of maternal HIV infection also allows for discussion of elective cesarean section and avoidance of breastfeeding, both of which are associated with lower HIV transmission rates. There is no evidence of an increase in fetal anomalies or other fetal harm associated with currently recommended antiretroviral regimens (with the exception of efavirenz). Serious or fatal maternal events are rare using currently recommended combination therapies. The USPSTF concluded that the benefits of screening all pregnant women substantially outweigh potential harms.
 
 Clinical Considerations
      • A person is considered at increased risk for HIV infection (and thus should be offered HIV testing) if he or she reports 1 or more individual risk factors or receives health care in a high-prevalence or high-risk clinical setting.
      • Individual risk for HIV infection is assessed through a careful patient history. Those at increased risk (as determined by prevalence rates) include: men who have had sex with men after 1975; men and women having unprotected sex with multiple partners; past or present injection drug users; men and women who exchange sex for money or drugs or have sex partners who do; individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users; persons being treated for sexually transmitted diseases (STDs); and persons with a history of blood transfusion between 1978 and 1985. Persons who request an HIV test despite reporting no individual risk factors may also be considered at increased risk, since this group is likely to include individuals not willing to disclose high risk behaviors.
      • There is good evidence of increased yield from routine HIV screening of persons who report no individual risk factors but are seen in high-risk or high-prevalence clinical settings. High-risk settings include STD clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs. High-prevalence settings are defined by the Centers for Disease Control and Prevention (CDC) as those known to have a 1% or greater prevalence of infection among the patient population being served. Where possible, clinicians should consider the prevalence of HIV infection or the risk characteristics of the population they serve in determining an appropriate screening strategy. Data are currently lacking to guide clinical decisions about the optimal frequency of HIV screening.
      • Current evidence supports the benefit of identifying and treating asymptomatic individuals in immunologically advanced stages of HIV disease (CD4 cell counts < 200 cells/mm3) with HAART. Appropriate prophylaxis and immunization against certain opportunistic infections have also been shown to be effective interventions for these individuals. Use of HAART can be considered for asymptomatic individuals who are in an earlier stage of disease but at high risk for disease progression (CD4 cell count < 350 cells/mm3 or viral load > 100,000 copies/mL), although definitive evidence of a significant benefit of starting HAART at these counts is currently lacking.
      • The standard test for diagnosing HIV infection, the repeatedly reactive enzyme immunoassay followed by confirmatory western blot or immunofluorescent assay, is highly accurate (sensitivity and specificity > 99%). Rapid HIV antibody testing is also highly accurate; can be performed in 10 to 30 minutes; and, when offered at the point of care, is useful for screening high risk patients who do not receive regular medical care (e.g., those seen in emergency departments), as well as women with unknown HIV status who present in active labor.
      • Early identification of maternal HIV seropositivity allows early antiretroviral treatment to prevent mother-to-child transmission, allows providers to avoid obstetric practices that may increase the risk for transmission, and allows an opportunity to counsel the mother against breastfeeding (also known to increase the risk for transmission). There is evidence that the adoption of "opt-out" strategies to screen pregnant women (who are informed that an HIV test will be conducted as a standard part of prenatal care unless they decline it) has resulted in higher testing rates. However, ethical and legal concerns of not obtaining specific informed consent for an HIV test using the "opt-out" strategy have been raised. While dramatic reductions in HIV transmission to neonates have been noted as a result of early prenatal detection and treatment, the extent to which detection of HIV infection and intervention during pregnancy may improve long-term maternal outcomes is unclear.
 
The Committee on Preventive Services for Women identified the primary gap relating to prevention of HIV infection not already addressed in the USPSTF recommendations as limiting counseling and screening only to pregnant women and high-risk adolescents and adults.
 
The HRSA-supported health plan coverage guidelines recommend counseling and screening for human immunodeficiency virus infection on an annual basis for all sexually active women. According to the committee, this recommendation is based on federal goals from the Centers for Disease Control and Prevention and on professional guidelines from the American College of Physicians, the Infectious Diseases Society of America, the American Medical Association and the American College of Obstetricians and Gynecologists.
  
CPT/HCPCS:
86689Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot)
86701Antibody; HIV 1
86703Antibody; HIV 1 and HIV 2, single result
87389Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result
87390Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; HIV-1
87535Infectious agent detection by nucleic acid (DNA or RNA); HIV 1, amplified probe technique, includes reverse transcription when performed
87806Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies
99401Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
99403Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes
99404Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes
G0432Infectious agent antibody detection by enzyme immunoassay (eia) technique, hiv 1 and/or hiv 2, screening
G0433Infectious agent antibody detection by enzyme linked immunosorbent assay (elisa) technique, hiv 1 and/or hiv 2, screening
G0435Infectious agent antibody detection by rapid antibody test, hiv 1 and/or hiv 2, screening
References: HIV Screening, April 1997: U.S. Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf05/hiv/hivrs.htm

PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association.