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Preventive Coverage of Work-up and Follow-up Services for Pre-exposure Prophylaxis for the Prevention of HIV for Independence Members


Policy Impacted


00.06.02

Purpose

The purpose of this communication is to provide notice regarding the preventive coverage of services received by an individual prior to beginning pre-exposure prophylaxis for the prevention of HIV and on-going follow-up and monitoring​ for Independence members.

Background

​On June 11, 2019, the US Preventive Services Task Force (USPSTF) issued a new recommendation for the coverage of pre-exposure prophylaxis for the prevention of human immunodeficiency virus (HIV) infection. The USPSTF recommends that clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk for HIV acquisition.​

On July 19, 2021, the ​​Departments of Labor, Health and Human Services (HHS) and the Treasury jointly issued a clarification on the preventive coverage pre-exposure prophylaxis (PrEP) for HIV as recommended by the USPSTF. ​​In accordance with the clarification, certain services received by an individual prior to beginning pre-exposure prophylaxis for HIV and monitoring services, which are essential to the efficacy of PrEP, are to be considered preventive consistent with the 2017 Centers for Disease Control and Prevention (CDC) guidelines on the PrEP for the prevention of HIV infection. These services are:
  • HIV Testing 
  • Hepatitis B Testing
  • Hepatitis C Testing 
  • Creatinine testing and calculated estimated creatine clearance (eCrCl) or glomerular filtration rate 
  • Pregnancy testing 
  • Sexually transmitted infection (STI) screening and counseling 
  • Adherence counseling​​​


Coverage Statement

As previously communicated, emtricitabine (200mg) with tenofovir disoproxil fumarate (300mg) and tenofovir disoproxil fumarate (300mg) are covered as a preventive service for the prevention of human immunodeficiency virus (HIV) for individuals who are considered high risk for HIV infection. High-risk factors for HIV infection are:

  • A sexual relationship with a partner living with HIV

  • Inconsistent use of condoms with a partner whose HIV status is unknown and who is at high risk

  • A sexually transmitted infection​ (i.e., syphilis, gonorrhea, or chlamydia) within the past 6 months

  • Shared use of drug injection equipment


Services received by an individual prior to the initiation of pre-exposure prophylaxis for the prevention of HIV and monitoring services are covered as a preventive service for individuals who are considered high risk for HIV infection. These services include the following tests: 

  • HIV Testing (at baseline then follow-up e​very 3 months) 

  • Hepatitis B Testing (at baseline then follow-up every 6 to 12 months)

  • Hepatitis C Testing (at baseline then follow-up annually)

  • Creatinine testing and calculated estimated creatine clearance (eCrCl) or glomerular filtration rate (at baseline then follow-up every 6 months)

  • Pregnancy testing (at baseline then follow-up every 3 months) 

  • Sexually transmitted infection (STI) screening and counseling (at baseline then follow-up every 3 to 6 months)

  • Adherence counseling​​​ (every 3 months)​

Coding

​HIV TESTING

CPT CODES
86689            
86701            
86702              
86703              
87389             
87390             
87391              
87536             
87806             

HCPCS CODES
G0432              Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening
G0433              Infectious agent antibody detection by enzyme-linked immunosorbent assay (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
S3645              HIV-1 antibody testing of oral mucosal transudate


HEPATITIS B TESTING

CPT CODES​
86704            
86705             
86706            
87340            
87341             

HCPCS CODE
G0499              Hepatitis B screening in nonpregnant, high-risk individual includes hepatitis B surface antigen (HBSAG), antibodies to HBSAG (anti-HBS) and antibodies to hepatitis B core antigen (anti-HBC), and is followed by a neutralizing confirmatory test, when performed, only for an initially reactive HBSAG result


HEPATITIS C TESTING

CPT CODES
86803              
87521            
87522            

HCPCS CODE
G0472              Hepatitis C antibody screening for individual at high risk and other covered indication(s)


CREATININE TESTING

CPT CODES
82565              
82575              


PREGNANCY TESTING

CPT CODE
81025              


STI SCREENING AND COUNSELING

SYPHILIS

CPT Codes
86592             
86780             
CHLAMYDIA

CPT Codes
86631            
86632            
87110              
87270              
87320              
87490        
87491           
87810         

GONORRHEA
      
CPT Codes
87590             
87591             
87850            

BEHAVIORAL COUNSELING FOR STI

HCPCS Codes
G0445              Semiannual high intensity behavioral counseling to prevent STIs, individual, face-to-face, includes education skills training & guidance on how to change sexual behavior


FOLLOW-UP VISITS WITH ADHERENCE COUNSELING

CPT CODES​
99401             
99402              
99403              
99404             


ICD10 CM DIAGNOSIS CODES FOR HIGH RISK FACTORS FOR HIV INFECTION:

A50.01         Early congenital syphilitic oculopathy
A50.02         Early congenital syphilitic osteochondropathy
A50.03         Early congenital syphilitic pharyngitis
A50.04         Early congenital syphilitic pneumonia
A50.05         Early congenital syphilitic rhinitis
A50.06         Early cutaneous congenital syphilis
A50.07         Early mucocutaneous congenital syphilis
A50.08         Early visceral congenital syphilis
A50.09         Other early congenital syphilis, symptomatic
A50.1           Early congenital syphilis, latent
A50.2           Early congenital syphilis, unspecified
A50.30         Late congenital syphilitic oculopathy, unspecified
A50.31         Late congenital syphilitic interstitial keratitis
A50.32         Late congenital syphilitic chorioretinitis
A50.39         Other late congenital syphilitic oculopathy
A50.40         Late congenital neurosyphilis, unspecified
A50.41         Late congenital syphilitic meningitis
A50.42         Late congenital syphilitic encephalitis
A50.43         Late congenital syphilitic polyneuropathy
A50.44         Late congenital syphilitic optic nerve atrophy
A50.45         Juvenile general paresis
A50.49         Other late congenital neurosyphilis
A50.51         Clutton's joints
A50.52         Hutchinson's teeth
A50.53         Hutchinson's triad
A50.54         Late congenital cardiovascular syphilis
A50.55         Late congenital syphilitic arthropathy
A50.56         Late congenital syphilitic osteochondropathy
A50.57         Syphilitic saddle nose
A50.59         Other late congenital syphilis, symptomatic
A50.6           Late congenital syphilis, latent
A50.7           Late congenital syphilis, unspecified
A50.9           Congenital syphilis, unspecified
A51.1           Primary anal syphilis
A51.2           Primary syphilis of other sites
A51.31         Condyloma latum
A51.32         Syphilitic alopecia
A51.39         Other secondary syphilis of skin
A51.41         Secondary syphilitic meningitis
A51.42         Secondary syphilitic female pelvic disease
A51.43         Secondary syphilitic oculopathy
A51.44         Secondary syphilitic nephritis
A51.45         Secondary syphilitic hepatitis
A51.46         Secondary syphilitic osteopathy
A51.49         Other secondary syphilitic conditions
A51.5           Early syphilis, latent
A51.9           Early syphilis, unspecified
A52.00         Cardiovascular syphilis, unspecified
A52.01         Syphilitic aneurysm of aorta
A52.02         Syphilitic aortitis
A52.03         Syphilitic endocarditis
A52.04         Syphilitic cerebral arteritis
A52.05         Other cerebrovascular syphilis
A52.06         Other syphilitic heart involvement
A52.09         Other cardiovascular syphilis
A52.10         Symptomatic neurosyphilis, unspecified
A52.11         Tabes dorsalis
A52.12         Other cerebrospinal syphilis
A52.13         Late syphilitic meningitis
A52.14         Late syphilitic encephalitis
A52.15         Late syphilitic neuropathy
A52.16         Charcot's arthropathy (tabetic)
A52.17         General paresis
A52.19         Other symptomatic neurosyphilis
A52.2           Asymptomatic neurosyphilis
A52.3           Neurosyphilis, unspecified
A52.71         Late syphilitic oculopathy
A52.72         Syphilis of lung and bronchus
A52.73         Symptomatic late syphilis of other respiratory organs
A52.74         Syphilis of liver and other viscera
A52.75         Syphilis of kidney and ureter
A52.76         Other genitourinary symptomatic late syphilis
A52.77         Syphilis of bone and joint
A52.78         Syphilis of other musculoskeletal tissue
A52.79         Other symptomatic late syphilis
A52.8           Late syphilis, latent
A52.9           Late syphilis, unspecified
A53.0           Latent syphilis, unspecified as early or late
A53.9           Syphilis, unspecified
A54.00         Gonococcal infection of lower genitourinary tract, unspecified
A54.01         Gonococcal cystitis and urethritis, unspecified
A54.02         Gonococcal vulvovaginitis, unspecified
A54.03         Gonococcal cervicitis, unspecified
A54.09         Other gonococcal infection of lower genitourinary tract
A54.1           Gonococcal infection of lower genitourinary tract with periurethral and accessory gland abscess
A54.21         Gonococcal infection of kidney and ureter
A54.22         Gonococcal prostatitis
A54.23         Gonococcal infection of other male genital organs
A54.24         Gonococcal female pelvic inflammatory disease
A54.29         Other gonococcal genitourinary infections
A54.30         Gonococcal infection of eye, unspecified
A54.31         Gonococcal conjunctivitis
A54.32         Gonococcal iridocyclitis
A54.33         Gonococcal keratitis
A54.39         Other gonococcal eye infection
A54.40         Gonococcal infection of musculoskeletal system, unspecified
A54.41         Gonococcal spondylopathy
A54.42         Gonococcal arthritis
A54.43         Gonococcal osteomyelitis
A54.49         Gonococcal infection of other musculoskeletal tissue
A54.5           Gonococcal pharyngitis
A54.6           Gonococcal infection of anus and rectum
A55              Chlamydial lymphogranuloma (venereum)
A56.00         Chlamydial infection of lower genitourinary tract, unspecified
A56.01         Chlamydial cystitis and urethritis
A56.02         Chlamydial vulvovaginitis
A56.09         Other chlamydial infection of lower genitourinary tract
A56.11         Chlamydial female pelvic inflammatory disease
A56.19         Other chlamydial genitourinary infection
A56.2           Chlamydial infection of genitourinary tract, unspecified
A56.3           Chlamydial infection of anus and rectum
A56.4           Chlamydial infection of pharynx
A56.8           Sexually transmitted chlamydial infection of other sites
A59.00         Urogenital trichomoniasis, unspecified
A59.01         Trichomonal vulvovaginitis
A59.02         Trichomonal prostatitis
A59.03         Trichomonal cystitis and urethritis
A59.09         Other urogenital trichomoniasis
A59.8           Trichomoniasis of other sites
A59.9           Trichomoniasis, unspecified
A60.00         Herpesviral infection of urogenital system, unspecified
A60.01         Herpesviral infection of penis
A60.02         Herpesviral infection of other male genital organs
A60.03         Herpesviral cervicitis
A60.04         Herpesviral vulvovaginitis
A60.09         Herpesviral infection of other urogenital tract
A60.1           Herpesviral infection of perianal skin and rectum
A60.9           Anogenital herpesviral infection, unspecified
A63.0           Anogenital (venereal) warts
A63.8           Other specified predominantly sexually transmitted diseases
A65              Nonvenereal syphilis
A70              Chlamydia psittaci infections
A74.0           Chlamydial conjunctivitis
A74.81         Chlamydial peritonitis
A74.89         Other chlamydial diseases
A74.9           Chlamydial infection, unspecified
B00.0           Eczema herpeticum
B00.1           Herpesviral vesicular dermatitis
B00.2           Herpesviral gingivostomatitis and pharyngotonsillitis
B00.3           Herpesviral meningitis
B00.4           Herpesviral encephalitis
B00.50         Herpesviral ocular disease, unspecified
B00.51         Herpesviral iridocyclitis
B00.52         Herpesviral keratitis
B00.53         Herpesviral conjunctivitis
B00.59         Other herpesviral disease of eye
B37.3           Candidiasis of vulva and vagina
B97.7           Papillomavirus as the cause of diseases classified elsewhere
N34.0          Urethral abscess
N34.1          Nonspecific urethritis
N34.2          Other urethritis
N34.3          Urethral syndrome, unspecified
N72             Inflammatory disease of cervix uteri
N73.0          Acute parametritis and pelvic cellulitis
N73.1          Chronic parametritis and pelvic cellulitis
N73.2          Unspecified parametritis and pelvic cellulitis
N73.3          Female acute pelvic peritonitis
N73.4          Female chronic pelvic peritonitis
N73.5          Female pelvic peritonitis, unspecified
N73.6          Female pelvic peritoneal adhesions (postinfective)
N73.8          Other specified female pelvic inflammatory diseases
N73.9          Female pelvic inflammatory disease, unspecified
P35.2           Congenital herpesviral [herpes simplex] infection
R85.81        Anal high risk human papillomavirus (HPV) DNA test positive
R87.810      Cervical high risk human papillomavirus (HPV) DNA test positive
R87.811      Vaginal high risk human papillomavirus (HPV) DNA test positive
Z11.3           Encounter for screening for infections with a predominantly sexual mode of transmission
Z20.2           Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission
Z72.51         High risk heterosexual behavior
Z72.52         High risk homosexual behavior
Z72.53         High risk bisexual behavior
Z72.89        Other problems related to lifestyle
Z77.21        Contact with and (suspected) exposure to potentially hazardous body fluids
Z86.19         Personal history of other infectious and parasitic diseases
Z91.42         Personal history of forced labor or sexual exploitation

9/17/2021