Does G0011 require prior authorization?

No, G0011 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for G0011?

Medicare facility rate: $21.71. Non-facility rate: $29.39. Work RVU: 0.45.

Verity

`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

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.45

Facility

$21.71

Non-Facility

$29.39

Documentation Required

All ICD-10, CPT and HCPCS codes billed for a preventive service should follow standard coding guidelines and be reported with diagnosis and procedure codes that identify the services as preventive and not for treatment of injury or illness.
Preventive services must be submitted with a designated wellness diagnosis code or maternity diagnosis code in the primary position where indicated (select the appropriate Designated Wellness Code from the pertinent Code Group).

Claims documentation should include clinical justification supporting the preventive purpose (e.g., age/risk status for screening, smoking history for lung cancer or AAA screening, pregnancy status for prenatal screenings) to support preventive benefit processing.

Genetic counseling/testing, behavioral and nutrition counseling visits subject to visit limits should be documented to show number of visits and medical necessity within preventive scope (e.g., BRCA counseling visit count for 3-visit limitation; nutrition counseling up to 3 visits when applicable).

Key Coverage Criteria

Preventive care services designated by the Affordable Care Act (ACA) and ACA-designated resources (USPSTF grade A or B recommendations; ACIP recommendations adopted by CDC Director; HRSA-supported comprehensive guidelines such as Bright Futures, Uniform Panel of Secretary's Advisory Committee on Heritable Disorders in Newborns and Children, HRSA Women's Preventive Services Guidelines).
Wellness examinations (preventive medicine comprehensive E/M services) for well-baby, well-child, well-adult and well-woman visits (CPT codes 99381-99387, 99391-99397, 99461; HCPCS G0402, G0438, G0439, S0610, S0612, S0613).
Age-specific well visit frequencies: ages 0 to 5 per AAP Bright Futures; ages 5 and above annual wellness exam; additional visits for women's contraception management.
Administration/interpretation of health risk assessment instruments (e.g., suicide risk assessment; sudden cardiac arrest/death risk assessment) (96160, 96161).
Autism screening (as part of preventive services).
Anxiety screening for adults, children and adolescents, including pregnant and postpartum persons (96127, 96161).

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

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