Hepatitis C virus (HCV) screening during pregnancy is a critical aspect of prenatal care, recommended by leading health organizations such as the ACOG, CDC, and USPSTF. This proactive testing allows for early identification of HCV in pregnant patients, facilitating crucial conversations between patients and healthcare providers about transmission risks to both mother and child. Accurate coding and billing are essential for ensuring these vital screenings are conducted and covered. This article provides a comprehensive guide to understanding CPT code 86803, the key procedural code for Hepatitis C antibody testing, and its covered diagnoses in the context of pregnancy.
Understanding Encounter and Procedural Codes for Hepatitis C Testing in Pregnancy
When ordering or billing for Hepatitis C tests during pregnancy, it’s important to utilize the correct codes to ensure proper processing and reimbursement. Here’s a breakdown of relevant encounter and procedural codes:
Encounter Codes (ICD-10-CM) for Ordering Tests
These ICD-10-CM codes are used to document the reason for the encounter when ordering Hepatitis C screening tests:
- Z11.59 – Encounter for screening for other infectious and parasitic diseases: This code is appropriate for general screening purposes when no specific risk factors are identified.
- Z22.8 – Carrier of other infectious disease: Used when the patient is known to be a carrier of an infectious disease, but the specifics are not the primary focus of this encounter.
- Z33.1 – Pregnant state, incidental: Indicates pregnancy is an incidental finding during an encounter for other reasons, but screening is being performed.
- Z33.3 – Pregnant state, gestational carrier: Relevant for gestational carriers undergoing routine pregnancy-related screenings.
- Z86.19 – Personal history of other infectious and parasitic diseases: Used when the patient has a history of infectious diseases, prompting screening.
- Z72.89 – Other problems related to lifestyle: Can be used in conjunction with HCPCS code G0472, particularly in situations related to risk factors that might not be explicitly classified elsewhere.
Procedural Codes for Hepatitis C Tests: CPT and HCPCS
Several procedural codes are available for Hepatitis C testing, with CPT code 86803 being the most commonly used for the initial antibody screening:
- 86803 – Hepatitis C antibody: This is the primary code for the initial screening test that detects the presence of Hepatitis C antibodies in the blood.
- 86804 – Hepatitis C antibody; confirmatory test (e.g., immunoblot): Used for confirmatory testing when the initial antibody test (86803) is positive.
- 87520 – Infectious agent detection by nucleic acid (DNA or RNA); hepatitis c, direct probe technique: Used for direct detection of the Hepatitis C virus genetic material.
- 87521 – Infectious agent detection by nucleic acid (DNA or RNA); hepatitis c, amplified probe technique, includes reverse transcription when performed: For amplified probe techniques to detect HCV genetic material, including reverse transcription if necessary.
- 87522 – Infectious agent detection by nucleic acid (DNA or RNA); hepatitis c, quantification, includes reverse transcription when performed: Used for quantifying the amount of HCV genetic material, including reverse transcription.
- 87902 – Infectious agent genotype by nucleic acid (DNA or RNA); Hepatitis c virus: For determining the genotype of the Hepatitis C virus.
- G0472 – Hepatitis C antibody screening at high risk and other covered indication(s): This HCPCS code is specific for Medicare and other payers following Medicare guidelines and covers:
- Single screening for adults not meeting high-risk criteria.
- Annual repeat screening for high-risk individuals with continued illicit injection drug use since a prior negative test.
It is crucial to confirm with your specific laboratory to determine the most appropriate code and process for ordering Hepatitis C tests for pregnant patients, as some labs may offer bundled codes.
Alt text: Sample laboratory test requisition form highlighting areas for coding and patient information, relevant to Hepatitis C screening during pregnancy.
Diagnosis Codes (ICD-10-CM) and CPT 86803: When is Hepatitis C Testing “Covered”?
The key to understanding “Cpt 86803 Covered Diagnosis” lies in the appropriate use of ICD-10-CM diagnosis codes, particularly when reporting Hepatitis C in pregnant women. While CPT code 86803 describes the test (Hepatitis C antibody), the diagnosis code justifies the medical necessity of the test and influences coverage.
The primary diagnosis code for Hepatitis C complicating pregnancy is:
- O98.41 – Viral hepatitis complicating pregnancy
This code is further subdivided by trimester:
- O98.411 – Viral hepatitis complicating pregnancy, first trimester
- O98.412 – Viral hepatitis complicating pregnancy, second trimester
- O98.413 – Viral hepatitis complicating pregnancy, third trimester
- O98.419 – Viral hepatitis complicating pregnancy, unspecified trimester
- O98.42 – Viral hepatitis complicating childbirth
- O98.43 – Viral hepatitis complicating the puerperium
When using codes from the O98.4 series, it is essential to include an additional code from categories B17-B19 to specify the type of viral hepatitis:
- B17.1 – Acute Hepatitis C
- B18.2 – Chronic Viral Hepatitis C
- B19.2 – Unspecified Viral Hepatitis C
For instance, a complete diagnosis code for chronic Hepatitis C complicating a first-trimester pregnancy would be O98.411, B18.2.
These diagnosis codes, when linked to the procedural code 86803, establish the “covered diagnosis” scenario. Routine prenatal screening for Hepatitis C, as recommended, is generally considered medically necessary and therefore “covered” when using appropriate encounter and diagnosis codes.
Alt text: Example of ICD-10 coding structure for viral hepatitis complicating pregnancy, showing parent code O98.41 and its trimester-specific subcategories.
Medicare Coverage and High-Risk Considerations for Hepatitis C Screening
Medicare has specific coverage guidelines for Hepatitis C screening, which are often followed by other payers. For Medicare beneficiaries, Hepatitis C screening is covered under the following conditions:
- High-Risk Individuals: A screening test is covered for adults at high risk for HCV infection. High-risk individuals include those with a current or history of illicit injection drug use and those who received blood transfusions before 1992.
- Repeat Screening for High-Risk: Annual repeat screening is covered for high-risk individuals who continue to engage in illicit injection drug use since their last negative screening.
- One-Time Screening for Adults Born 1945-1965: A single screening test is covered for adults born between 1945 and 1965, even if they do not meet the high-risk criteria.
The determination of “high-risk” is made by the patient’s primary care physician or practitioner based on their medical history.
For pregnant patients, routine Hepatitis C screening is broadly recommended and generally covered by payers, even beyond these Medicare-specific high-risk criteria. However, it is always prudent to verify coverage with the specific payer to avoid potential issues.
If coverage denials occur, the ACOG Payment Advocacy and Policy Portal is a valuable resource for ACOG members to seek assistance.
Evaluation and Management (E/M) Coding for Hepatitis C Screening Visits
When billing for Evaluation and Management (E/M) services related to Hepatitis C screening, appropriate CPT codes should be used based on whether the patient is new or established and the complexity of the visit.
| CPT Codes (Minutes) | Descriptions |
|---|---|
| New Patient Office Visits: | |
| – 99202 (15 – 29) – 99203 (30 – 44) – 99204 (45 – 59) – 99205 (60 – 74) | Office or other outpatient visit for the E/M of a new patient requiring a medically appropriate history and/or examination. |
| Established Patient Office Visits: | |
| – 99211 – 99212 (10-19) – 99213 (20-29) – 99214 (30-39) – 99215 (40-54) | Office or other outpatient visit for the E/M of an established patient requiring a medically appropriate history and/or examination. |
| Preventive Medicine Counseling: | |
| – 99401 (15) – 99402 (30) – 99403 (45) – 99404 (60) | Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure). |
These E/M codes can be used in conjunction with CPT code 86803 and appropriate diagnosis codes to provide comprehensive billing for Hepatitis C screening during pregnancy.
Conclusion: Ensuring Access to Hepatitis C Screening Through Proper Coding
Accurate coding with CPT code 86803 and relevant ICD-10-CM diagnosis codes is paramount for ensuring pregnant patients receive recommended Hepatitis C screenings and that healthcare providers are appropriately reimbursed. Understanding the nuances of “cpt 86803 covered diagnosis,” particularly in the context of pregnancy and associated ICD-10 codes like O98.41 and B18.2, is crucial for effective practice management and optimal patient care. By adhering to these guidelines and staying updated on payer-specific policies, healthcare providers can confidently offer and bill for this essential prenatal screening.
Alt text: Screenshot of the ACOG Payment Advocacy and Policy Portal website interface, highlighting the “Ask a Coding Question” section for member support.
