HIV PrEP preventive services revealed in 2024 HCPCS update

by: Julia Kyles, CPC Nov 10, 2023

CMS has not released a final national coverage determination (NCD) for pre-exposure prophylaxis (PrEP) to prevent human immunodeficiency virus (HIV). And CMS did not discuss the service in the physician fee schedule final rule. But practices and clinics can find previews of the service in the 2024 HCPCS update, the relative value units (RVU) file for the 2024 Medicare and appendix B of proposed decision memo CAG-00464N.

Based on the HCPCS file, a practice will bill G0011 when a physician or qualified health care professional (QHP) counsels a patient for at least 15 minutes. When a member of the clinical staff performs the counseling, a practice will bill G0013.

The sessions include a risk assessment and counseling the patient on risk reduction and medication adherence.

A practice will report G0012 for the PrEP injection.

The following chart contains the full descriptors and national payment rates for the non-facility (NF) and facility (Fac.) settings, which were calculated with the 2024 relative value units and conversion factor.

Code	Full descriptor	NF	Fac.
G0011	Individual counseling for pre-exposure prophylaxis (PrEP) by physician or qualified health care professional (QHP) to prevent human immunodeficiency virus (HIV), includes HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence, 15-30 minutes	$25.86	$21.93
G0012	Injection of pre-exposure prophylaxis (PrEP) drug for HIV prevention, under skin or into muscle	$14.08	N/A
G0013	Individual counseling for pre-exposure prophylaxis (PrEP) by clinical staff to prevent human immunodeficiency virus (HIV), includes: HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence	$22.92	$8.51
Sources: Addendum B – relative value units and related information used in CY 2024 final rule (zip) and January 2024 alpha-numeric HCPCS files (zip).

CMS has not issued a final version of the NCD for Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection. However, based on the proposed version of NCD 210.15, patients will not have a copay or deductible for PrEP counseling and injections.

According to the proposed NCD, CMS intends to cover PrEP “using antiretroviral drugs (whether oral or injectable) approved by the US Food and Drug Administration (FDA) to prevent HIV infection,” for high-risk patients.

Practices would be able to report up to seven counseling sessions a year.

CMS also proposes to cover up to seven individual counseling visits, every 12 months, that include HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence. Counseling must be furnished by a physician or other health care practitioner and individuals must be competent and alert at the time that counseling is provided.

Watch Part B News for more information when CMS releases the final NCD.

Blog Tags: CMS

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