Hepatitis B virus (HBV) infection remains a significant public health concern. Effective screening programs are crucial in identifying infected individuals, enabling timely treatment and preventing further transmission. For healthcare providers, accurate coding of Hepatitis B screening is essential not only for proper patient care but also for ensuring appropriate financial reimbursement. Understanding the correct diagnosis codes for hep B screening is vital for healthcare organizations to maintain financial stability and support ongoing screening efforts.
Conditions for Hepatitis B Screening Coverage
Medicare and Medicaid Services (CMS) recognize the importance of HBV screening and provide coverage for eligible individuals. However, certain conditions must be met to qualify for coverage of the Hepatitis B surface antigen (HBsAg) serologic test. These conditions are designed to ensure that screening is conducted in appropriate settings and for the populations most likely to benefit.
A healthcare professional prepares a Hepatitis B screening test, highlighting the importance of accurate diagnosis codes for reimbursement.
Firstly, the screening must be ordered by a primary care physician or practitioner who is an eligible Medicare provider, and it must be performed within a primary care setting. This emphasizes the role of primary care in preventive health services. Secondly, the laboratory tests used for screening must be approved or cleared by the U.S. Food and Drug Administration (FDA) and used in accordance with FDA-approved labeling and Clinical Laboratory Improvement Act (CLIA) regulations. This ensures the reliability and accuracy of the screening process.
Patient eligibility also plays a key role in coverage. CMS provides specific guidelines based on patient groups:
- Pregnant Women: Screening is covered for pregnant women during their first prenatal visit. Rescreening at the time of delivery is also covered for those with new or ongoing risk factors. This coverage applies to each pregnancy, irrespective of previous hepatitis B vaccination or negative HBsAg test results, reflecting the importance of screening during pregnancy to prevent mother-to-child transmission.
- Asymptomatic, Nonpregnant Adolescents and Adults at High Risk: Asymptomatic, nonpregnant adolescents and adults identified as being at high risk for HBV infection are eligible for annual HBV screening coverage. The definition of “high risk” and further details on “primary care physician/practitioner” and “primary care setting” are available in the National Coverage Determination for Screening for HBV Infection.
Diagnosis Coding for Hepatitis B Screening: Ensuring Reimbursement
Accurate diagnosis coding is crucial when submitting claims for Hepatitis B screening. The appropriate diagnosis codes signal the reason for the encounter and justify the medical necessity of the screening test, directly impacting reimbursement.
For pregnant women undergoing HBV screening (for CPT codes 86704, 86706, 87340, and 87341), the primary diagnosis code to report is Z11.59 (Encounter for screening for other viral diseases). This code clearly indicates the purpose of the encounter is for viral disease screening. This should be accompanied by one of the following pregnancy supervision diagnosis codes, depending on the trimester and type of pregnancy:
- Z34.00 – Encounter for supervision of normal first pregnancy, unspecified trimester
- Z34.80 – Encounter for supervision of other normal pregnancy, unspecified trimester
- Z34.90 – Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
- O09.90 – Supervision of high risk pregnancy, unspecified, unspecified trimester
When screening pregnant women at high risk for HBV, report the relevant CPT code along with Z11.59 and Z72.89 (Other problems related to lifestyle), in addition to one of the more specific ICD-10-CM codes that detail the trimester of pregnancy:
- Z34.00 – Z34.03 – Encounter for supervision of normal first pregnancy
- Z34.80 – Z34.83 – Encounter for supervision of other normal pregnancy
- Z34.90 – Z34.93 – Encounter for supervision of normal pregnancy, unspecified
- O09.90 – O09.93 – Supervision of high risk pregnancy, unspecified
For non-pregnant adolescents and adults at high risk for HBV infection, CMS coverage for procedure code G0499 is contingent upon reporting specific diagnosis codes that denote high-risk status. The primary screening diagnosis code remains Z11.59. In addition, Z72.89 may also be appropriate to further specify lifestyle factors contributing to risk.
For subsequent visits for high-risk individuals, coverage for G0499 is allowed when reported with Z11.59 and one of the following high-risk condition codes, as applicable to the patient’s situation:
- F11.10-F11.99 (Opioid-related disorders)
- F13.10-F13.99 (Sedative, hypnotic or anxiolytic-related disorders)
- F14.10-F14.99 (Cocaine-related disorders)
- F15.10-F15.99 (Other stimulant-related disorders)
- Z20.2 (Contact with and exposure to viral hepatitis B)
- Z20.5 (Contact with and exposure to viral hepatitis C)
- Z72.52 (High risk heterosexual behavior)
- Z72.53 (High risk homosexual behavior)
For more comprehensive information on billing and coding specifications, refer to MLN Matters MM9859 provided by CMS.
Conclusion
Correctly applying diagnosis codes for hep B screening is not merely a billing requirement; it is an integral part of ensuring access to vital preventive healthcare services. By understanding and accurately utilizing the appropriate diagnosis codes, healthcare providers can secure necessary reimbursement, support continued HBV screening programs, and contribute to the broader effort to combat Hepatitis B infection within communities. Staying updated with the latest CMS guidelines and coding updates is crucial for maintaining compliance and optimizing reimbursement for these essential services.
