PrEP or Pre-Exposure Prophylaxis is an advanced HIV prevention method in which people who do not have HIV but are at high risk for getting it (through sex or injection drug use) take a PrEP pill daily to reduce their risk. In July 2012, the U.S. Food and Drug Administration approved the combination medication tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC) to use it as PrEP among sexually active adults who are at risk for HIV infection. Now, the Centers for Disease Control and Prevention (CDC) also bats for PrEP to prevent HIV infection and stresses the role of healthcare providers in utilizing this prevention method apart from HIV screening and diagnosis.
Crucial Role of Providers
As per the CDC, PrEP is safe and highly effective in preventing HIV infection and can be even more effective when combined with other prevention methods such as condom use, drug abuse treatment and treatment for people living with HIV. Also, PrEP should be offered to people who are at very high risk for getting it, which include about 1 in 4 sexually active gay and bisexual men, 1 in 5 people who inject drugs, and 1 in 200 sexually active heterosexual adults. If daily PrEP can reduce the risk of getting infected with HIV from sex by more than 90 percent, it can reduce HIV risk in people who inject drugs by 70 percent.
However, the lack of knowledge and access to these services shrouds the chance of prevention. This is where CDC points out the significant role of healthcare providers. When more healthcare providers know about and prescribe PrEP, many people who can benefit from PrEP would take the pill daily and more HIV infections could be prevented. CDC gives the following recommendations to healthcare providers regarding this.
- Test your patients for HIV as a regular part of medical care, and counsel them on HIV risks and continued use of prevention methods.
- Follow the 2014 PrEP Clinical Practice Guidelines in order to perform the recommended test and prescribe PrEP to the patients without HIV, but at high risk for HIV infection.
- Give counseling to the patients who can benefit from PrEP regarding how to take medication and help them apply for insurance or other programs that pay for PrEP.
- Schedule appointments for patients who are using PrEP every three months for follow-up, including HIV testing and prescription refills.
Medical Coding for PrEP
There are no official medical billing codes available specifically for PrEP. However, you can use the following ICD-10 codes and CPT codes while prescribing PrEP depending upon the patient’s condition.
- Z72.5: High risk sexual behavior
- Z20.82: Contact with and (suspected) exposure to other viral communicable diseases
- Z20: Contact with and (suspected) exposure to communicable diseases
- Z20.2: Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission
- Z20.6: Contact with and (suspected) exposure to HIV
- Z77.21: Contact with and (suspected) exposure to potentially hazardous body fluids
- W46: Contact with hypodermic needle: “the appropriate 7th character is to be added to each from category W46” A-initial encounter, D-subsequent encounter, S-sequela
- W46.0: Contact with hypodermic needle (hypodermic needle stick NOS)
- W46.1: Contact with contaminated hypodermic needle
- Z20.8: Contact with and (suspected) exposure to other communicable diseases
- Z79: Long term (current) drug therapy. Includes long term (current) drug use for prophylactic purposes
- 99401: Prevention counseling (15 minutes)
- 99402: Prevention counseling (30 minutes)
- 99403: Prevention counseling (45 minutes)
- 99404: Prevention counseling (60 minutes)
The medical coding and billing in this regard can be rather confusing. Providers can always obtain reliable support from an experienced medical billing and coding company to assign the correct codes corresponding to the patient’s condition and in compliance with the insurance plan.