Billing & Coding Resources

PrEP Billing & Coding Tools

Comprehensive billing and coding resources for Illinois healthcare providers prescribing PrEP. Find the correct codes, understand reimbursement guidelines, and streamline your billing processes.

View CPT Codes ICD-10 Codes Resources

Accurate Coding

Current CPT and ICD-10 codes for all PrEP services

Reimbursement Info

Insurance coverage and payment guidelines

Time Saving

Quick reference guides and cheat sheets

CPT Codes

Current Procedural Terminology Codes

Essential CPT codes for PrEP-related services, consultations, and procedures. Updated to reflect current billing requirements.

Evaluation & Management

CPT Code Description Visit Type Notes
99213 Office/Outpatient Visit - Established Patient Follow-up 15-20 min, low complexity
99214 Office/Outpatient Visit - Established Patient Follow-up 25-30 min, moderate complexity
99204 Office/Outpatient Visit - New Patient Initial 45-60 min, moderate complexity
99205 Office/Outpatient Visit - New Patient Initial 60-75 min, high complexity

Laboratory Services

CPT Code Test Description Frequency Purpose
87806 HIV-1 Antigen(s), with HIV-1 & HIV-2 antibodies Baseline & q3 months HIV screening
80053 Comprehensive Metabolic Panel Baseline & q6 months Kidney function monitoring
87591 Neisseria gonorrhoeae, direct probe Baseline & q3 months STI screening
87510 Chlamydia trachomatis, direct probe Baseline & q3 months STI screening
86781 Hepatitis B surface antigen (HBsAg) Baseline Hepatitis B screening

Counseling & Education

CPT Code Service Description Duration Application
99401 Preventive counseling - individual 15 minutes Risk reduction counseling
99402 Preventive counseling - individual 30 minutes Extended risk counseling
G0445 High-intensity behavioral counseling 30 minutes STI prevention counseling

Important Coding Notes

  • Always verify current CPT codes and coverage policies with specific payers
  • Document medical necessity and risk factors in patient records
  • Use appropriate modifiers when billing for multiple services on the same day
  • Follow payer-specific guidelines for frequency limitations and prior authorization requirements
ICD-10 Codes

Diagnostic Codes for PrEP Services

Essential ICD-10 diagnosis codes for documenting medical necessity and ensuring proper reimbursement for PrEP-related services.

Primary PrEP Indication Codes

Z87.891 PRIMARY

Personal history of nicotine dependence

Can be used when patient has history of substance use contributing to HIV risk

Z72.52 PRIMARY

High risk sexual behavior

Most commonly used code for PrEP prescribing based on sexual risk factors

Z72.53 COMMON

High risk heterosexual behavior

Specific code for heterosexual individuals at high risk for HIV

Z87.891 SUPPORT

Personal history of drug dependence

For patients with history of injection drug use

Screening & Monitoring

ICD-10 Code Description Use Case Frequency
Z11.4 Encounter for screening for HIV HIV testing visits Every 3 months
Z11.3 Encounter for screening for STI STI screening visits Every 3 months
Z13.89 Encounter for other screening General health screening Every 6 months
Z51.81 Encounter for therapeutic drug level monitoring PrEP adherence monitoring As needed

Counseling & Risk Assessment

Z
Z29.81
Encounter for prophylactic immunotherapy
Z
Z71.7
Human immunodeficiency virus counseling
Z
Z71.89
Other specified counseling
Z
Z72.51
High risk homosexual behavior
Z
Z87.19
Personal history of other diseases

Best Practices

  • Use Z72.52 as primary diagnosis for most PrEP patients
  • Document specific risk factors in clinical notes
  • Use screening codes for follow-up visits

Common Pitfalls

  • Don't use only screening codes without risk factors
  • Avoid generic codes when specific ones exist
  • Don't forget to update codes annually

Medical Coding Modifiers

Essential modifiers for accurate billing and reimbursement in healthcare services

Common Medical Billing Modifiers

Reference guide for frequently used modifiers in medical billing

Modifier Description Usage
25 Significant, separately identifiable evaluation and management service Used when E/M service is provided on same day as procedure
50 Bilateral procedure Applied when procedure is performed on both sides
51 Multiple procedures Used for second and subsequent procedures in same session
52 Reduced services Indicates partial reduction or elimination of service
53 Discontinued procedure Procedure discontinued due to extenuating circumstances
59 Distinct procedural service Separate procedure not normally reported together
62 Two surgeons When two surgeons work as co-surgeons
76 Repeat procedure by same physician Procedure repeated on same day by same physician
77 Repeat procedure by another physician Procedure repeated on same day by different physician
78 Unplanned return to OR Return to operating room during postoperative period
79 Unrelated procedure during postop period Unrelated procedure by same physician during postop period
80 Assistant surgeon Surgical assistant services
81 Minimum assistant surgeon Minimum surgical assistant services
82 Assistant surgeon when qualified resident unavailable Assistant when resident not available
90 Reference (outside) laboratory Laboratory procedures performed by outside lab
91 Repeat clinical diagnostic laboratory test Same lab test repeated on same day
95 Synchronous telemedicine service Real-time telemedicine encounters

Anatomical Modifiers

LT Left side
RT Right side
E1-E4 Eyelid (upper/lower)
F1-F9 Finger digits
T1-T9 Toe digits

Level II (HCPCS) Modifiers

GA Waiver of liability
GG Performance and payment
GT Synchronous telemedicine
GY Statutorily excluded
GZ Expected denial

Important Modifier Guidelines

Usage Rules:

  • • Multiple modifiers can be used on same procedure
  • • List modifiers in order of priority
  • • Verify payer-specific modifier requirements

Documentation:

  • • Medical record must support modifier use
  • • Clear documentation prevents claim denials
  • • Regular training ensures proper application
Resources & Downloads

Billing Reference Materials

Access comprehensive billing guides, quick reference sheets, and official resources to streamline your PrEP billing processes.

Official Billing Code Reference

Complete PrEP billing guide from TalkPrEP

Comprehensive PDF guide containing all current CPT codes, ICD-10 codes, and billing best practices specifically for PrEP services. This official resource includes coverage policies, reimbursement guidelines, and coding examples.

Download PDF Guide Visit TalkPrEP
Billing Code Reference
Official TalkPrEP Resource
CPT Codes ✓ Included
ICD-10 Codes ✓ Included
Coverage Policies ✓ Included

Quick Reference Checklist

Printable checklist of essential codes and documentation requirements for each PrEP visit type.

Insurance Coverage Guide

Comprehensive guide to coverage policies for major insurance plans in Illinois, including prior authorization requirements.

Billing Best Practices

Step-by-step guide to optimize billing processes, reduce claim denials, and improve reimbursement rates.

Need Help with Billing & Coding?

Our team is available to assist with specific billing questions, claim denials, and coding challenges. Get expert support when you need it most.

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Keep Your Codes Current

Billing codes are updated annually. Always verify current codes with official sources and your billing department. Last updated: 2024