Executive Summary
The Human Immunodeficiency Virus (HIV) prevention landscape continues to evolve. HIV testing remains a critical activity supported by state, territorial, and local health departments (LHDs). Core HIV prevention and care activities led by local health departments depend on robust testing efforts to identify new infections and link people living with HIV (PLWH) to care. Public health services have traditionally been viewed as free, and a move toward billing and coding for these services requires a paradigm shift for both LHD staff and individuals seeking services. For LHDs, coding is a comprehensive approach and not isolated to just one clinical service. Most LHDs establish coding programs to include all of the clinical services that they provide.
Coding for HIV, STI and related services is an essential practice for programs that are preparing for billing third- party payers. Beginning to properly code for services is a critical step in improving revenue cycle management and developing sustainable systems.
Once the LHD has established a billing infrastructure, it can seek revenue across programs for reimbursable services such as HIV testing and counseling. Ultimately, state or local health departments should decide to bill after carefully assessing the communities they serve. If billing is the right decision for the LHD, dwindling public funds may be used for the most vulnerable populations. Despite challenges, LHDs have remained persistent and have developed creative ways to establish successful billing programs.
Billing for HIV services of insured individuals makes sense as a way to save money for federal, state, and local governments, assure proper stewardship of public funds and promote public and private payer participation.
Many of the children and adults seen by LHDs either already have insurance or are potentially eligible for insurance coverage for HIV services. Public programs including Medicaid, fund HIV services for individuals with limited financial means.
Finally, there are a number of laws and program requirements that require LHDs to code and bill for services. LHDs provide services and receive funding through public programs. Compliance with the various program requirements require LHDs to bill as appropriate. There are many factors that determine the ability of LHDs to bill for HIV services: local delivery and billing practices for a range of public health services, HIV services volume, and the public and commercial insurance markets.
This paper provides an overview for public health HIV billing, including billing Medicare, Medicaid, and private insurance; but these activities do not exist in isolation. They fit into a bigger picture of planning, budget and policy development, organizational objectives, grants, programs, and community priorities. Billing is one way to think and act more like a business. Billing allows health departments to identify and tap into existing sources of revenue to survive, even thrive, through tough economic times when people often need care most. Patients with private or commercial insurance pay premiums for health care benefits covered by their health plan.
In addition, this paper provides a general understanding of the coding guidelines for public health HIV services provided through local health departments (LHDs). This paper provides a high level review of:
- Medical code sets used for coding and billing HIV services.
- Format and conventions for ICD-10, CPT-4, and Evaluation and Management (E/M) codes.
- Basic coding guidelines by correctly referencing official coding guidelines to support accurate code assignment.
- Basic CPT coding steps by appropriately appending a CPT code with the correct modifier, as applicable.
- Documentation needed in order to code.
The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated. The conventions and instructions of the classification take precedence over guidelines.
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