CPT code G0475 coved ICD 10 code and denial codes

Billing Requirements

Effective for claims with dates of service on or after April 13, 2015, MACs will recognize new HCPCS code G0475 (HIV antigen/antibody, combination assay, screening) as a new covered service for HIV screening.

NOTE: HCPCS G0475 will appear in the January 1, 2017, CLFS; in the January 1, 2016, Integrated Outpatient Code Editor (IOCE); in the January 2016 Outpatient Prospective Payment System (OPPS); and in the January 1, 2016, Medicare Physician Fee Schedule (MPFS). HCPCS Code G0475 will be effective retroactive to April 13, 2015, in the IOCE and OPPS.

For services from April 13 - September 30, 2015, inclusive, the diagnosis codes are:

ICD-9 Code Descriptor
V22.0 Supervision of normal first pregnancy
V22.1 Supervision of other normal pregnancy
V23.9 Supervision of unspecified high-risk pregnancy
V69.8 Other problems related to lifestyle
V73.89 Special screening examination for other specified viral diseases
V69.2 High risk sexual behavior
Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester
Z34.01 Encounter for supervision of normal first pregnancy, first trimester
Z34.02 Encounter for supervision of normal first pregnancy, second trimester
Z34.03 Encounter for supervision of normal first pregnancy, third trimester
Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester
Z34.81 Encounter for supervision of other normal pregnancy, first trimester
Z34.82 Encounter for supervision of other normal pregnancy, second trimester
Z34.83 Encounter for supervision of other normal pregnancy, third trimester
Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester
Z34.92 Encounter for supervision of normal pregnancy, second trimester
Z34.93 Encounter for supervision of normal pregnancy, third trimester
O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester
O09.91 Supervision of high risk pregnancy, unspecified, first trimester
O09.92 Supervision of high risk pregnancy, unspecified, second trimester
O09.93 Supervision of high risk pregnancy, unspecified, third trimester
Z72.89 Other problems related to lifestyle
Z11.4 Encounter for screening for human immunodeficiency virus [HIV]
Z72.51 High risk heterosexual behavior
Z72. 52 High risk homosexual behavior
Z72.53 High risk bisexual behavior

On professional claims, the place of service must be either 81 (independent laboratory) or 11 (office).

If claims are received for screenings that exceed the maximum number allowed per year, the claim line item will be denied with the following remittance codes:

** Claim Adjustment Reason Code (CARC) 119: “Benefit maximum for this time period or occurrence has been reached.”

** Remittance Advice Remark Code (RARC) N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination
as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the CMS website. If you do not have web access, you may contact the contractor to request a copy of the NCD.” and


** Group Code: CO (Contractual Obligation).

Note that the next eligible date for the service will be provided on all Common Working File (CWF) provider query screens (HUQA, HIQA, HIQH, ELGA, ELGH, and PRVN).
Claims with HCPCS Code G0475 for beneficiaries between the ages of 15 and 65 without regard to risk must also be submitted with a primary diagnosis code of either V73.89 (ICD- 9) or Z11.4 (ICD-10). If that primary code is not present, the line item will be denied using the following messages:

** CARC 167 – “This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information
REF), if present.”

** RARC N386 – “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or
service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the CMS website. If you do not have web access, you may contact the contractor to request a copy of the NCD.”

** Group Code: CO (Contractual Obligation).

Claims with HCPCS Code G0475 for beneficiaries less than age 15 or greater than age 65 with increased risk must also be submitted with a primary diagnosis code of either V73.89 (ICD-9) or Z11.4 (ICD-10) and a secondary diagnosis code that denotes the high risk. The ICD-9 secondary codes are V69.2 or V69.8. The ICD-10 secondary diagnosis codes are Z72.51, Z72.89, Z72.52, or Z72.53. If that secondary code is not present, the line item will be denied using the following messages:

** CARC 6: “The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment Information REF), if present.”

** RARC N129: “Not eligible due to the patient’s age.”

** Group Code: CO (Contractual Obligation).

Effective for claims with dates of service on or after April 13, 2015, MACs will deny lineitems on claims for pregnant beneficiaries denoted by a secondary diagnosis code above denoting pregnancy, if HCPCS Code G0475, HIV screening, or CPT code 80081, obstetric panel, and primary diagnosis code V73.89/ Z11.4, as appropriate, are not present on the claim. Such line item denials will result in the following remittance messages:

** CARC 11: “The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information
REF), if present.

** RARC N386 – “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item
or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the CMS website. If you do not have web access, you may contact the contractor to request a copy of the NCD.”

** Group Code: CO (Contractual Obligation).

Institutional claims for G0475 submitted on Types of Bill (TOB) 12X, 13X, 14X, 22X, and 23X will be paid based on the CLFS with dates of service on or after January 1, 2017. MACs will apply their pricing to claims with dates of service of April 13, 2015, through December 31, 2016. Such claims submitted on TOB 85X will be paid based on reasonable cost for dates of service beginning with April 13, 2015.

• Persons who have acquired or request testing for other sexually transmitted infectious diseases;

• Persons with a history of blood transfusions between 1978 and 1985;