L28886

 

HEPATITIS C ANTIBODY IN THE ESRD AND NON-ESRD SETTING

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

Indications

• Medicare will consider testing for the antibody to hepatitis C to be medically reasonable and necessary when one or more the following conditions have been met:

o Exposure to HCV-infected blood.

o The presence of abnormal liver function tests with no apparent cause for abnormality.

o Signs and symptoms exhibiting liver damage including fatigue, jaundice, nausea, pain in the abdomen, fever, muscle aches, joint pain swollen legs/feet, loss of appetite, diarrhea and vision loss.

o Increased risk factors within the ESRD setting.

Limitations

• Medicare will not cover HCV testing performed for the purpose of routine screening.

Coding Information

 

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

72x Clinic - Hospital Based or Independent Renal Dialysis Center

85x Critical Access Hospital

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0300 Laboratory - General Classification

0301 Laboratory - Chemistry

0302 Laboratory - Immunology

0303 Laboratory - Renal Patient (Home)

0304 Laboratory - Non-Routine Dialysis

0305 Laboratory - Hematology

0306 Laboratory - Bacteriology & Microbiology

0307 Laboratory - Urology

0309 Laboratory - Other Laboratory

 

 

CPT/HCPCS Codes

 

86803 HEPATITIS C ANTIBODY;

 

 

Documentation Requirements

• Medical record documentation maintained by the provider must substantiate the medical necessity of the services being billed.

o In addition, documentation that the service was performed must be included in the patient’s medical record.

o This information is normally found in the history and physical, office/progress notes, hospital notes, and/or procedure report.

• If HCV testing is performed for the indication of abnormal liver function tests with no apparent cause for abnormality, documentation should include copies of the liver function test results.

• If HCV testing is performed for the indication of suspected exposure to HCV, the medical records should include the time frame of suspected exposure and the circumstances surrounding the exposure.

• If HCV testing is performed for the indication of signs and symptoms of liver damage without apparent cause, the documentation should present a detailed history of symptoms exhibited by the patient.

Utilization Guidelines

• It is expected that testing for hepatitis C will be performed:

o In the ESRD setting:

 Upon admission and annually.

 When an exposure occurs which might result in seroconversion.

 When there is an unexplained new elevation of the transaminases.

 If there is an increased risk of exposure identified within the facility.

o In the non-ESRD setting:

o When an exposure occurs which might result in seroconversion.

o When there is an unexplained new elevation of the transaminases.

Treatment Logic

• Hepatitis C is a blood-bourne virus that can cause significant damage to the liver.

• The majority of infected individuals remain undiagnosed.

• Although there is a high prevalence of infection, the hepatitis C virus (HCV) is not an easily transmitted disease.

• The main route of transmission is by sharing equipment for injecting drug use, mainly via blood contaminated needles and syringes, spoons, filters and water.

• Chronic infection associated with HCV commonly leads to liver damage.

• Testing for the hepatitis C antibody is used to confirm the presence of hepatitis C infection.

Sources of Information and Basis for Decision

 

Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50(No. RR-5):17-24.

 

FCSO LCD 29190, Hepatitis C Antibody in the ESRD and non-ESRD setting, 02/02/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Kim, A.I. & Sabb, S. Treatment of hepatitis C. The American Journal of Medicine (2005) 118, 808-815

 

McInnis-Shaw, V. (2005) What is HCV? Retrieved from http://hepatitis-central.com/?hcv/what March 10, 2006.

 

Mandell, Bennett, & Dolin: Principles and Practice of Infectious Diseases, 6th ed., (2005) Copyright © 2005 Churchill Livingstone, An Imprint of Elsevier

 

Persistently abnormal liver function tests: Marker of occult hepatitis C? (2004) Retrieved from medicalnewstoday.com March 29, 2006.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

CMS LCD L28886 HEPATITIS C ANTIBODY IN THE ESRD AND NON-ESRD SETTING