STI counseling, testing covered by Medicare

March 25, 2012

Questions include details regarding Medicare coverage of sexually transmitted infections. Find out the answers to your pressing coding questions.

A: Sexually transmitted infections (STIs) are an important cause of morbidity in the United States and have both health and economic consequences. Additionally, the presence of an STI during pregnancy may result in significant health complications for the mother and infant. For these reasons, the Centers for Medicare and Medicaid Services (CMS) is now covering high-intensity behavioral counseling (HIBC) to prevent STI counseling and screening lab tests for STIs when specific criteria are met.

MLN Matters number MM7610, dated January 26, says a new code will be reimbursed by Medicare if referred and provided by a Medicare-eligible primary care provider (specialties of general and family practice, internal medicine, obstetrics and gynecology, pediatrics, geriatrics, certified nurse midwife, nurse practitioner, certified clinical nurse specialist, or physician assistant) in a primary care setting (physician office, outpatient hospital, independent clinic, or state or local public health clinic).

This code went into effect November 8, and will be fully implemented July 2. You can bill this code on the same date of service (DOS) as an annual wellness visit, or evaluation and management (E/M) service, or during the global billing period for obstetrical care. If G0445 is billed on the same DOS as an E/M code, a distinct diagnosis code (separate from the diagnosis code[s] for the E/M service) should be billed for G0445. Also, an E/M code should not be billed when the sole reason for the visit is HIBC to prevent STIs. Only one G0445 can be billed per patient, per DOS.

As the description for G0445 indicates, the service is payable semi-annually. When applying frequency limitations to HIBC services, Medicare will allow both a claim for the professional service and a claim for the facility fee, when appropriate. Medicare coinsurance and Part B deductible are waived for G0445.

HIBC elements and patient risk factors. HIBC is intended to promote sexual risk reduction or risk avoidance, which includes each of the following topics, allowing flexibility for appropriate patient-focused elements: education, skills training, and guidance on how to change sexual behavior.

Individual high/increased risk sexual behaviors include any of the following: multiple sex partners, inconsistent use of barrier protection, sex under the influence of alcohol or drugs, sex in exchange for money or drugs, age (24 years or younger and sexually active for women for chlamydia and gonorrhea), having an STI within the past year, intravenous drug use (hepatitis B only), and men having sex with men engaging in high-risk sexual behavior regardless of age.

Community social factors, such as a high prevalence of STIs in the community populations, also should be considered when determining high/increased risk for chlamydia, gonorrhea, syphilis, and when recommending HIBC.