Overview:
CMS has finalized its decision to reimburse for HCV screening in primary care settings, for individuals who are Medicare eligible and either “high risk” or born between 1945-1965. “High risk” is defined as persons with a current or past history of illicit injection drug use; and persons who have a history of receiving a blood transfusion prior to 1992. See below for the CMS decision summary or view the full decision here.
Decision Summary from The Centers for Medicare & Medicaid Services (CMS):
The evidence is adequate to conclude that screening for Hepatitis C Virus (HCV), consistent with the grade B recommendations by the U.S. Preventive Services Task Force (USPSTF), is reasonable and necessary for the prevention or early detection of an illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B, as described below.
Therefore, CMS will cover screening for HCV with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations, when ordered by the beneficiary’s primary care physician or practitioner within the context of a primary care setting, and performed by an eligible Medicare provider for these services, for beneficiaries who meet either of the following conditions.
- A screening test is covered for adults at high risk for Hepatitis C Virus infection. “High risk” is defined as persons with a current or past history of illicit injection drug use; and persons who have a history of receiving a blood transfusion prior to 1992. Repeat screening for high risk persons is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test.
- A single screening test is covered for adults who do not meet the high risk as defined above, but who were born from 1945 through 1965.
The determination of “high risk for HCV” is identified by the primary care physician or practitioner who assesses the patient’s history, which is part of any complete medical history, typically part of an annual wellness visit and considered in the development of a comprehensive prevention plan. The medical record should be a reflection of the service provided.
For the purposes of this national coverage determination (NCD), a primary care setting is defined by the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, clinics providing a limited focus of health care services, and hospice are examples of settings not considered primary care settings under this definition.
For the purposes of this NCD, a “primary care physician” and “primary care practitioner” will be defined consistent with existing sections of the Social Security Act (§1833(u)(6), §1833(x)(2)(A)(i)(I) and §1833(x)(2)(A)(i)(II)).
§1833(u)
(6) Physician Defined.—For purposes of this paragraph, the term “physician” means a physician described in section 1861(r)(1) and the term “primary care physician” means a physician who is identified in the available data as a general practitioner, family practice practitioner, general internist, or obstetrician or gynecologist.
§1833(x)(2)(A)(i)
(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or
(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in section 1861(aa)(5));
*UPDATE from National Viral Hepatitis Roundtable*
On June 2, 2014, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare will cover hepatitis C testing at no cost to beneficiaries whom the U.S. Preventive Services Task Force recommends be screened. Specifically, Medicare will cover a one-time test for beneficiaries who are born from 1945 through 1965 and ongoing tests for those who are at risk. This is an important step forward in the fight against the hepatitis C epidemic and in identifying the 50% -75% of people who don’t know they have hepatitis C.
Medicare has updated its website to include information about this new benefit. The test will be covered only if it is ordered by a primary care doctor.
CMS has also released a “Medicare Learning Network” (MLN) bulletin for medical providers with information about the new benefit, including billing codes.
NVHR recommends that all Medicare beneficiaries who don’t know their hepatitis C status ask their doctor for a test. We also encourage NVHR members to send this information to medical providers who care for Medicare patients so they are aware of this important change in policy.
Last Updated on January 25, 2020 by HepFree NYC
