PrEP for HIV: how to prepare for CMS' proposed switch to Medicare Part B coverage

The Centers for Medicare & Medicaid Services (CMS) last year proposed to transition coverage of oral or injectable HIV pre-exposure prophylaxis (PrEP) drugs from Medicare Part D to Part B. PrEP drugs are approved by the Food and Drug Administration (FDA) to prevent HIV infection.

Now, to ensure patients have uninterrupted access to their medications, CMS is encouraging physicians and other Part B providers to start preparing their billing systems to submit claims for PrEP drugs and related counseling. That way, they can immediately transition to Part B coverage if CMS releases a final National Coverage Decision.

CMS anticipates that physicians and other providers will use the following HCPCS codes to report PrEP-related work:

• J0739 — “Injection, cabotegravir, 1mg, FDA-approved prescription, only for use as HIV pre-exposure prophylaxis (not for use as treatment for HIV).” Short descriptor: “HIV prep, inj, cabotegravir.
• G0011 — “Individual counseling for pre-exposure prophylaxis (PrEP) by physician or QHP (qualified health professional) 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.” Short descriptor: “HIV prep counsel, md 15-30m.”
• G0013 — “Individual counseling for pre-exposure prophylaxis (PrEP) by clinical staff to prevent human immunodeficiency virus (HIV), includes: HIV risk assessment (initial or continued assessment of risk), HIV risk reduction and medication adherence.” Short descriptor: “HIV prep counsel, clin staff.”
• G0012 — “Injection of pre-exposure prophylaxis (PrEP) drug for HIV prevention, under skin or into muscle.” Short descriptor: “Inj, Prep drug for HIV prev.”

A diagnosis code is required to report the above codes to Medicare, so physicians will also want to be aware of the new diagnosis code Z29.81, “Encounter for HIV pre-exposure prophylaxis.”

Review the CMS fact sheet (PDF) to learn more about how you can prepare for the possible upcoming coverage change, including information about enrollment, billing, claims processing, and coding. 

— Kent Moore, AAFP Senior Manager, Payment Strategies

Posted on April 22, 2024