HUMAN IMMUNODEFICIENCY VIRUS (HIV) TESTING (Diagnosis)

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Arron Armstrong
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1 HUMAN IMMUNODEFICIENCY VIRUS (HIV) TESTING (Diagnosis) NCD Source: Program Memorandum AB , Effective ; Medicare NCD Manual, July 2003 Release; October 2003 Release; October 2004 Release; October 2005 Release; October 2006 Release; January 2007 Release; Medicare Trans. 1531, Effective , October 2008 Release, October 2010 Release CMS (Medicare) has determined that HIV Testing (Diagnosis) (CPT Codes 86689; Antibody: HIV-1; Antibody: HIV-2; Antibody: HIV-1 and HIV-2, single assay; 87390; 87391; 87534; 87535; 87537; 87538) is only medically necessary and, therefore, reimbursable by Medicare when ordered for patients with any of the diagnostic conditions listed below in the ICD-9-CM Codes Covered by Medicare Program. If you are ordering this test for a diagnostic condition other than those listed below, please have your patient sign and date an Advanced Beneficiary Notice (ABN). All ICD-9-CM codes provided must be consistent with the documentation in the patient s medical records for the date of service. NOTE: Please be aware that it is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid. In addition, the procedure must be reasonable and necessary for that diagnosis. Documentation within the beneficiary's medical record must support the necessity for the test(s) provided for each date of service. For additional information, see the Limited Coverage Guidebook Information provided in this section. ICD-9-CM Codes Covered by Medicare Program: Salmonella septicemia Coccidiosis (Isoporiasis) Cryptosporidiosis Other specified protozoal intestinal diseases Primary tuberculous infection Pulmonary tuberculosis Other respiratory tuberculosis Tuberculosis of meninges and central nervous system Tuberculosis of intestines, peritoneum and mesenteric glands Tuberculosis of bones and joints Tuberculosis of genitourinary system Tuberculosis of other organs Miliary tuberculosis Listeriosis Diseases due to other mycobacteria Pneumococcal septicemia Septicemia (Pseudomonas) Actinomycotic infections (includes Nocardia) Pseudomonas infection 042 HIV disease (Acute retroviral syndrome, AIDS-related complex) Progressive multifocal leukoencephalopathy Other non-arthropod-borne viral diseases of central nervous system Postvaricella encephalitis/ varicella (hemorrhagic) pneumonitis Postvaricella myelitis Chickenpox (with complication) Herpes zoster, with meningitis Herpes zoster with other nervous system complications 1 of 5

2 Herpes zoster with ophthalmic complication Herpes zoster with other specified complications Herpes zoster unspecified or no complication mentioned Herpes simplex, eczema hepeticum Genital herpes Herpetic gingivostomatitis/ meningoencephalitis Herpes simplex with ophthalmic complications Herpetic septicemia / whitlow Herpes simplex- visceral, meningitis, otitis externa Herpes simplex myelitis Herpes simplex, other Herpes simplex / unspecified, no complications mentioned Measles (includes morbilli, rubeola) Measles keratitis / other Measles unspecified Viral hepatitis B with hepatic coma Viral hepatitis B without mention of hepatic coma Acute or unspecified hepatitis C with hepatic coma Hepatitis delta without mention of active hepatitis B disease with hepatic coma Chronic hepatitis C with hepatic coma Other specified viral hepatitis with hepatic coma Acute hepatitis C without mention of hepatic coma Hepatitis delta without mention of active hepatitis B disease or hepatic coma Chronic hepatitis C without hepatic coma Other specified viral hepatitis without hepatic coma Unspecified viral hepatitis with hepatic coma Unspecified viral hepatitis C without hepatic coma Unspecified viral hepatitis C with hepatic coma Unspecified viral hepatitis without hepatic coma Molluscum contagiosum Viral warts Plantar warts Cat-scratch disease Cytomegaloviral disease Other specified diseases due to Chlamydiae Retrovirus specified / unspecified Retrovirus / other Parvovirus B Other specified chlamydial infection Unspecified chlamydial infection Leishmaniasis Bartonellosis Congenital syphilis Early syphilis symptomatic Uveitis due to secondary syphilis Secondary syphilis of viscera and bone Secondary syphilis, relapse Other forms of secondary syphilis Unspecified secondary syphilis Early syphilis, latent Cardiovascular syphilis / aneurysm of aorta, aortitis Syphilitic endocarditis Other specified cardiovascular syphilis 2 of 5

3 093.9 Cardiovascular syphilis, unspecified Neurosyphilis Other specified neurosyphilis Neurosyphilis, unspecified Other forms of late syphilis, with symptoms 096 Late syphilis, latent Other and unspecified syphilis Gonococcal infections, acute of lower genitourinary tract Gonococcal infections, upper genitourinary tract (acute, chronic), eye, joint,pharynx, rectum, other specified sites Other venereal disease; chancroid, lymphogranuloma, venereum, granuloma inguinale, Reiter s disease Other nongonococcal urethritis Other venereal diseases due to Chlamydia trachomatis Other specified venereal disease Veneral Disease unspecified Dermatophytosis of nail Pityriasis versicolor Candidiasis Candidiasis of other specified sites Candidiasis of unspecified site Coccidioidomycosis Histoplasmosis Blastomycotic infection Aspergillosis Cryptococcosis 118 Opportunistic mycoses Strongyloidiasis Toxoplasmosis Trichomonal vulvovaginitis Phthirus pubis Scabies Specific infections by free living amebae Pneumocystosis Other specified infectious and parasitic disease (for example, microsporidiosis) Kaposi s sarcoma Malignant neoplasm of cervix uteri Burkitt s tumor or lymphoma Lymphosarcoma, other named variants Hodgkin s disease Malnutrition of moderate degree Malnutrition of mild degree Unspecified protein-calorie malnutrition Iron deficiency anemias Anemia, unspecified Primary thrombocytopenia Neutropenia, neutropenia unspecified, other Hemophagocytic syndromes f(amilial hemophagocytic lymphohistocytosis or reticulosis, hemophagoicytic syndrome infection-associate, histiocytic syndromes, macrophage activation syndrome) Decreased white blood cell count/ leukocytopenia, lymphocytopenia, other Elevated white blood cell count / lymphocytosis and monocytosis (symptomatic), leukocytosis (unspecified), leukemoid reaction, plasmacytosis, basophilia Bandemia 3 of 5

4 Other elevated white blood cell count Neutropenic splenomegaly Other specified organic brain syndromes (chronic) Personality changes due to conditions classified elsewhere Chronic meningitis Other frontotemporal dementia Mild cognitive impairment, so stated [excludes: altered mental status, cerebral degeneration, change in mental status, cognitive deficits following (late effects of) cerebral hemorrhage or infarction, cognitive impairment due to intracranial or head injury, cognitive impairment due to late effect of intracranial injury, dementia, mild memory disturbance, neurologic neglect syndrome, personality change, nonpsychotic] Unspecified disease of spinal cord Encephalopathy unspecified Other encephalopathy Mononeuritis of upper limbs and mononeuritis multiplex Other specified idiopathic peripheral neuropathy Chorioretinitis, unspecified Other primary cardiomyopathies Chronic sinusitis 481 Pneumococcal pneumonia Other bacterial pneumonia Pneumonia due to streptococcus, staphylococcus, other specified bacteria Bacterial pneumonia, unspecified Pneumonia in cytomegalic inclusion disease 486 Pneumonia, organism unspecified Other spontaneous pneumothorax Other specified alveolar and parietoalveolar pneumonopathies Oral aphthae Leukoplakia of oral mucosa Ulcer of esophagus Barrett s esophagus Nephropathy with unspecified pathological lesion in kidney Other specified disorders resulting from impaired renal function Other viral diseases complicating pregnancy (use for HIV I and II) Other cellulitis and abscess Seborrheic dermatitis Other psoriasis Lichenification and lichen simplex chronicus Other specified diseases of hair and hair follicles Diseases of sebaceous glands Fever and other physiologic disturbances of temperature regulation * Febrile non-hemolytic transfusion reaction Other malaise and fatigue Abnormal loss of weight Lack of expected normal physiological development, unspecified Enlargement of lymph nodes Respiratory abnormality, unspecified Shortness of breath Cough, hemoptysis, abnormal sputum Diarrhea Nonspecific serologic evidence of human immunodeficiency virus Wasting disease V01.71 Contact or exposure to varicella V01.79 Contact or exposure to other viral diseases 4 of 5

5 V71.5 Observation following alleged rape or seduction ICD-9-CM Codes That May Be Denied or Do Not Support Medical Necessity Generally, ICD-9-CM codes that are not listed in the ICD-9-CM Codes Covered by Medicare Program section will not be covered because they indicate that the tests are performed for screening purposes or because they do not support medical necessity. * Frequency Limitations: The Western Blot test should be performed only after documentation that the initial EIA tests are repeatedly positive or equivocal on a single sample. If initial serologic tests confirm an HIV infection, repeat testing is not indicated. If initial serologic tests are HIV EIA negative and there is no indication for confirmation of infection by viral RNA detection, the interval prior to retesting is 3 6 months. * Testing for evidence of HIV infection using serologic methods may be medically appropriate in situations where there is a risk of exposure to HIV. However, in the absence of documented AIDS defining or HIV-associated disease, an HIV-associated sign or symptom, or documented exposure to a known HIVinfected source, the testing is considered by Medicare to be screening and thus is not covered by Medicare (for example, history of multiple blood component transfusions, exposure to blood or body fluids not resulting in consideration of therapy, history of transplant, history of illicit drug use, multiple sexual partners, same-sex encounters, prostitution, or contact with prostitutes). 5 of 5

Human Immunodeficiency Virus (HIV) Testing (Diagnosis)

190.14 - Human Immunodeficiency Virus (HIV) Testing (Diagnosis) Other Names/Abbreviations HIV, HIV-1, HIV-2, HIV1/2, HTLV III, Human T-cell lymphotropic virus, AIDS, Acquired immune deficiency syndrome