ACOG guidelines for HIV screening don’t always acknowledge coding reality
The College urges “opt-out” screening—but many states require that, even then, you counsel the patient and have her sign a consent form
IN THIS ARTICLE
The author reports no financial relationships relevant to this article.
Routine screening for the human immunodeficiency virus (HIV) is recommended for all women 19 to 64 years old, according to guidelines issued in August 2008 by the American College of Obstetricians and Gynecologists (ACOG). In addition, ACOG recommends that women outside that age range who have a risk factor for HIV infection undergo targeted screening.
To accomplish these goals, ACOG suggests “opt-out” HIV screening, in which the patient is notified that HIV testing will be performed as a routine part of gynecologic and obstetric care unless she declines it.
Opt-out testing may not always be feasible, however, because many payers still require that you counsel the patient about the HIV test before it is performed, as well as have her sign a consent form.
Information about individual states’ requirements for testing, counseling, and informed consent can be found at the Compendium of State HIV Testing Laws, Quick Reference Guide for Clinicians (March 17, 2009), prepared by the National HIV/AIDS Clinicians’ Consultation Center at www.nccc.ucsf.edu/StateLaws/About%20Compendium/Quick%20Reference%20Guide.pdf.
The patient may be offered the test during any of the following:
- her preventive health checkup
- an office visit for a presenting problem
- a scheduled obstetric visit.
When you provide counseling, bill for it!
Counseling for HIV in the absence of the condition is considered a preventive service, which is reported using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual), based on total counseling time between 15 and 60 minutes (reported in 15-minute increments). Such preventive counseling can be reported in addition to a problem E/M service by adding the modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the problem E/M code. It can also be reported separately at the time of an obstetric visit. However, such counseling is not covered when it is conducted during a preventive exam.
Diagnostic coding, following these ICD-9 rules, lets the payer know why the service is being rendered:
- Report V73.89 (Screening for other specified viral disease) if the patient is being seen to determine her HIV status.
- Report V69.8 (Other problems related to lifestyle) as a secondary diagnosis if the patient is in a group known to be at high risk of HIV infection.
- Report V65.44 (HIV counseling) for counseling provided during the encounter for the test, or use this code to report the visit at which the patient returns to discuss her result.
The patient’s risk factors for HIV should be reviewed annually to assess the need for retesting.
The ACOG guidelines are unclear as to what, exactly, “routine” testing means. Is an ObGyn expected to test a patient once in her lifetime, annually, or any time her life partner changes?
These specifics are not addressed in the ACOG recommendations. Based on similar recommendations from the Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force (USPSTF), however, you might surmise the following:
- Test all patients 19 to 64 years old for HIV at least once.
- Test all patients at high risk of contracting HIV annually. (High-risk groups include women who receive a blood transfusion, practice unsafe sex, or have a new sexual partner who has not been tested.)
- Test all women each time they become pregnant.
For patients in all health-care settings, CDC guidelines, which are comparable to ACOG’s and those of the USPSTF, also recommend that:
- HIV screening be carried out after the patient is notified that testing will be performed, unless she declines (opt-out screening)
- any person who is at high risk of contracting HIV be screened at least annually
- separate written consent for HIV testing not be required (general consent for medical care should be sufficient to encompass consent for HIV testing)
- prevention counseling not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings
- among pregnant women, HIV screening be included in the routine panel of prenatal screening tests
- every pregnant woman be screened for HIV after she is notified that testing will be performed, unless she declines (opt-out screening)
- separate written consent for HIV testing not be required for pregnant women (general consent for medical care should be sufficient to encompass consent for HIV testing)
- repeat screening in the third trimester be carried out in certain jurisdictions that have an elevated rate of HIV infection among pregnant women.
Obviously, the CDC’s call for opt-out screening and its recommendation against informed consent for HIV testing contradict the requirements of some states, so it is important to know the regulations where you practice.