Z11.4 — Encounter for screening for human immunodeficiency virus [HIV]
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For pregnant women, documentation of HIV testing discussion/notification (opt-out process), test results, and any repeat testing performed in the third trimester when applicable.
- For point-of-care/oral testing (e.g., Orasure/OraQuick), documentation of test type, specimen source (oral fluid vs. blood), test operator/site, and any necessary confirmatory testing and linkage-to-care steps following a reactive result.
- For OraQuick POC testing: reactive point-of-care results should be confirmed by laboratory-based confirmatory testing (implied by statement that reactive tests need confirmation by more specific Western blot).
- Serum or plasma specimens submitted for testing after a reactive (preliminary positive) result from any rapid HIV test (per Note: 'Laboratories should use this same testing algorithm, beginning with an antigen/antibody combination immunoassay, with serum or plasma specimens submitted for testing after a reactive (preliminary positive) result from any rapid HIV test').
Key Coverage Criteria
- For screening persons for HIV infection, according to the recommendations of the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention;
- Initial testing for HIV with a DA-approved antigen/antibody combination immunoassay that detects HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen to screen for established infection with HIV-1 or HIV-2 and for acute HIV-1 infection. No further testing is required for specimens that are nonreactive on the initial immunoassay.
- Further testing of specimens with a reactive antigen/antibody combination immunoassay result (or repeatedly reactive, if repeat testing is recommended by the manufacturer or required by regulatory authorities), if tested with an FDA-approved antibody immunoassay that differentiates HIV-1 antibodies from HIV-2 antibodies. [...]
- Testing of specimens that are reactive on the initial antigen/antibody combination immunoassay and nonreactive or indeterminate on the HIV-1/HIV-2 antibody differentiation immunoassay when tested with an FDA-approved HIV-1 nucleic acid test (NAT) according to the following criteria: - A reactive HIV-1 NAT result and nonreactive HIV-1/HIV-2 antibody differentiation immunoassay result indicates laboratory evidence for acute HIV-1 infection; - A reactive HIV-1 NAT result and indeterminate HIV-1/HIV [...]
- Note: Laboratories should use this same testing algorithm, beginning with an antigen/antibody combination immunoassay, with serum or plasma specimens submitted for testing after a reactive (preliminary positive) result from any rapid HIV test.
- The Orasure oral HIV test kit (OraSure Technologies, Bethlehem, PA) for the same indications as standard HIV testing;
4 Active Policies
CIGNA-0530 — Nucleaic Acid Pathogen Testing - (0530)
CIGNA-0398 — Transvaginal Ultrasound, Non-Obstetrical - (0398)
AETNA-CPB-0542 — HIV Testing
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
Related Codes
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