Section 3: Billing Instructions

Facilities participating in the HIV Primary Care Medicaid Program must comply with all standard Medicaid billing practices established through the New York State Medicaid Management Information System (MMIS). It should be noted, however, that the program has several features which depart from standard Medicaid billing practices.

Patient Eligibility

HIV Primary Care Medicaid Program visits may only be billed for patients who remain in the Medicaid fee-for-service system and are not enrolled in managed care.

The HIV Testing and HIV Counseling without Testing visits may be billed for any patient whose HIV status is unknown or in question.

The HIV Counseling (Positive) visit may be billed for any patient with a positive test result (preliminary or confirmed) or for a patient with an established diagnosis of HIV infection.

Clinical HIV primary care visits (the Initial/Annual Comprehensive HIV Medical Evaluation and the HIV Monitoring visits) may only be billed for patients with a confirmed diagnosis of HIV infection.

Rapid HIV Tests and Laboratory Services

The costs of the following are included in the visit rate, which Medicaid pays directly to the provider:

  1. rapid HIV testing and control kits, and
  2. most laboratory services associated with the two clinical visits. The provider is responsible for purchasing the rapid HIV test kits and for paying the laboratory performing the services associated with the clinical visits.

The costs of the following laboratory services are not included in any visit rate and should be billed by the laboratory performing the tests:

  • HIV tests, which not CLIA-waived and must be performed by a licensed clinical laboratory, including conventional screening (EIA) and confirmatory tests (Western Blot);
  • HIV viral load testing (CPT Code Y8706);
  • HIV resistance testing:
    • Genotypic (CPT Code 87901),
    • Phenotypic (CPT Code 87903).

See www.hivguidelines.org, Adult HIV Guidelines and Pediatric and Adolescent HIV Guidelines, for laboratory assessments and screening tests appropriate for the management of HIV-infected patients.

Same-Day Billing

Same-day billing is allowed for HIV Primary Care Medicaid Program visits and any other general hospital outpatient clinic visit or free standing clinic visit for which a Medicaid rate has been established. Same-day billing is also allowed for some combinations of HIV Primary Care Medicaid Program visits. For a summary, see Chart 1, Allowable Same Day Payments (PDF, KB, 1pg.).

Utilization Limits and Medical Record Documentation Requirements

Chart 2, Billing Codes, Utilization Limits, Medical Documentation (PDF, KB, 1pg.), includes a summary of utilization limits and medical record documentation standards for each HIV Primary Care Medicaid Program visit. Utilization caps of one per patient per year are in place for the HIV Counseling without Testing visit and the Initial/Annual Comprehensive HIV Medical Evaluation. The remaining three visits have utilization thresholds, which represent expectations of visit usage based on current clinical practice. Exceeding the threshold may result in on-site utilization reviews by the Department of Health's peer review agent.

Providers enrolled in the HIV Primary Care Medicaid Program must meet all medical record documentation requirements set forth in Sections 405.10 (for hospitals) and 751.7 (for diagnostic and treatment centers) of Title 10 NYCRR. Additional HIV-specific medical record documentation standards are included in Chart 2. Thorough documentation, including documentation of follow up activities, will prevent adverse quality of care and utilization review findings.

In all cases of same-day billing, the patient's medical record must document that distinctively different services were provided for each visit billed.

HIV Testing in the Emergency Department (ED)

As of November 1, 2006, hospital emergency departments may bill the HIV Testing Visit and the HIV Counseling (Positive) Visit. The HIV Counseling without Testing Visit may not be billed for ED patients. The following billing rules apply to HIV testing in emergency departments.

  • EDs may bill the HIV Testing Visit only when rapid tests, which provide results within a single visit, are used.
  • Same-day billing is allowed for the HIV Testing Visit and an ED visit.
  • The ED must provide HIV counseling and linkage to medical services, including confirmatory testing, when a patient's test result is a preliminary positive. In these cases, the hospital may bill an ED visit, an HIV Testing Visit, and an HIV Counseling (Positive) Visit on the same day.
  • EDs may not bill the HIV Primary Care Medicaid Program for patients who are admitted for inpatient services.

For more information, see Section 5: Frequently Asked Questions about HIV Testing Prevention Services in Hospital Emergency Department.