Medicare Covers Screening for Hepatitis C

As part of the expanded preventative services mandates under the Affordable Care Act, Medicare is now covering screenings for Hepatitis C (HCV) effective with claims starting June 2, 2014. Recent information from the Centers for Medicare and Medicaid Services (CMS) provides details on how this new service is covered for beneficiaries under both Medicare Part A and Part B. For the complete CMS guidance please refer to Medlearn Matters Article MM8871 or Chapter 18 of the Medicare Claims Processing Manual.

In general, preventive services must meet all of the following coverage criteria:

• Reasonable and necessary for the prevention or early detection of illness or disability;
• Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF); and
• Appropriate for individuals entitled to benefits under Part A or enrolled under Part B.

Specifically regarding HCV, Medicare will cover screening for HCV when ordered by the beneficiary's primary care physician or practitioner within the context of a primary care setting, and performed by an eligible Medicare provider for these services, for beneficiaries who meet either of the following conditions:

• A screening test is covered for adults at high risk for HCV infection. “High risk” is defined as persons with a current or past history of illicit injection drug use; and persons who have a history of receiving a blood transfusion prior to 1992. Repeat screening for high risk persons is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test.
   
• A single screening test is covered for adults who do not meet the high risk as defined above, but who were born from 1945 through 1965.

The determination of “high risk” is made by the primary care physician or practitioner who assesses the patient's history and includes the screening in the development of a comprehensive prevention plan. For services provided under the category of beneficiaries born between the years 1945 and 1965, who are not considered to be high risk, HCV screening is limited to one per lifetime. New G code G0472, Hepatitis C antibody screening for individual at high risk and other covered indication(s), will be used.

Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827