Point32Health would like to remind providers of our billing requirements regarding HIV pre-exposure prophylaxis (PrEP) medication, and to make sure you’re aware of the availability of a new ICD-10 code specific to HIV PrEP.
As we communicated in the September 2023 issue of Insights and Updates for Providers, the prescribing of HIV PrEP medication, as well as ongoing follow-up and monitoring and other related services, are considered preventive services and are required under the Patient Protection and Affordable Care Act to be covered with no cost sharing responsibility for the member when rendered by an in-network provider.
How to bill
When billing for PrEP and other HIV services for Tufts Health Plan members, providers should bill the appropriate CPT procedure code with the correct ICD-10 diagnosis code — or, for procedure codes not listed on the policy, if the claim is for an evidence-based service with a United States Preventive Services Task Force (USPSTF) A or B rating, the service may be identified by adding modifier 33 to the procedure code.
For Harvard Pilgrim commercial plans, these services must now be billed with the appropriate ICD-10 diagnosis code in addition to the procedure code in order to be reimbursed.
New ICD-10 code available for HIV PrEP
Please be aware that the Centers for Disease Control and Prevention recently released a new ICD-10 code specific to HIV PrEP. Going forward, please bill Z29.81 to report an encounter for HIV pre-exposure prophylaxis.
As a reminder, you can refer to our Harvard Pilgrim Patient Protection and Affordable Care Act (Federal Health Care Reform) policy and Tufts Health Plan Preventive Services Payment Policy for billing guidance to ensure that no member cost sharing is inappropriately applied.
Director, Provider Relations & Communications
Senior Manager, Provider Communications
Joseph O’Riordan, Susan Panos, Stephen Wong,