L29190

 

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.

 

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 / ADA CDT 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. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

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