- Preventive Services Guide
- Medicare Preventive Services Resource Guide
- Alcohol Misuse and Counseling
- Annual Wellness Visit Screening
- Bone Mass Measurements
- Cardiovascular Disease Screening Tests
- Colorectal Cancer Screening
- Counseling to Prevent Tobacco Use
- Depression Screening
- Diabetes Screening
- Diabetes Self-Management Training
- Glaucoma Screening
- Hepatitis B Virus Screening
- Hepatitis B Virus Vaccine and Administration
- Hepatitis C Virus Screening
- Human Immunodeficiency Virus Screening
- Influenza Virus Vaccine and Administration
- Initial Preventive Physical Examination
- Intensive Behavioral Therapy for Cardiovascular Disease
- Intensive Behavioral Therapy for Obesity
- Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low-Dose Computed Tomography
- Medical Nutrition Therapy
- Pneumococcal Vaccine and Administration
- Prolonged Preventive Services
- Prostate Cancer Screening
- Screening for Cervical Cancer with Human Papillomavirus Tests
- Screening for Sexually Transmitted Infections and HIBC to Prevent STIs
- Screening Mammography
- Screening Pap Tests
- Screening Pelvic Examinations
- Ultrasound Screening for Abdominal Aortic Aneurysm
- Vaccinations
- Related Articles
- Medicare Preventive Services Resource Guide
- The Annual Wellness Visit
- Medicare’s Annual Wellness Visit in Illinois: Understanding the Benefit and Preventing Denials
- Medicare’s Annual Wellness Visit in Minnesota: Understanding the Benefit and Preventing Denials
- Medicare’s Annual Wellness Visit in Wisconsin: Understanding the Benefit and Preventing Denials
Preventive Services Guide
Human Immunodeficiency Virus Screening
HIV attacks cells that help the body fight infection making a person vulnerable to other infections. Nearly 1.2 million Americans are now living with HIV infection and about 50,000 people become infected every year.
Coverage Criteria and Frequency Limits
- Covered annually for beneficiaries at increased risk for HIV infection
- Covered for a maximum of three times per term of pregnancy for pregnant Medicare beneficiaries
- When diagnosis of pregnancy is known
- During the third trimester
- At labor, if ordered by woman’s physician
- Coverage provided for both standard and FDA approved HIV rapid-screening tests
Increased Risk Factors
- 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 who have sex partners who have
- Individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users
- Individuals being treated for STDs
- Individuals with history of blood transfusion between 1978 and 1985
- Individuals who request HIV test despite reporting no individual risk factors
HCPCS/CPT Coding
- G0432: Infectious agent antibody detection by EIA technique, HIV-1 or HIV-2, screening
- G0433: Infectious agent antibody detection by ELISA technique, HIV-1 and/or HIV-2, screening
- G0435: Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening
- G0475: HIV antigen/antibody, combination assay, screening
- 80081: Obstetric panel (includes HIV testing)
Diagnosis Coding
- ICD-10 Codes
- Increased risk factors not reported – Z11.4
- Increased risk factors reported – Z11.4 and Z72.51, Z72.52, Z72.53, or Z72.89
- Pregnant Medicare beneficiaries – Z11.4 and Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, or O09.93
- Note: Additional ICD-10 codes may apply. See the CMS ICD-10 webpage for individual Change Requests (CRs) and the specific ICD-10-CM codes Medicare covers for this service, and contact your Medicare Administrative Contractor (MAC) for guidance
Cost Sharing
- Copayment/coinsurance waived
- Deductible waived
Reimbursement
Nonparticipating Providers
- Nonparticipating reduction applies
- Limiting charge provision applies
Common Claim Denial Reasons
- Beneficiary received HIV screening within past year (not because of pregnancy)
- Beneficiary already received three HIV screenings within current pregnancy
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 130
- CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 210.7
- MLN® Educational Tool: Medicare Preventive Services
Reviewed 10/12/2023