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Indications and Limitations for hepatitis Test Ordering
Arthur Rosenthal, Ph.D
Recent enforcement of certain Medicare rules concerning ordering of hepatitis tests have brought into focus certain limitations in terms of patient status and the requirements in terms of frequency of ordering allowed. The following rules apply to Medicare and in most cases to Medicaid patients:
- Patients who have not been immunized against hepatitis B may have a hepatitis B surface antigen (HbsAg) ordered monthly on the 585 ICD-9 code. They may have an annual hepatitis B surface antibody (HbsAb) test under 585 or more frequently if separately justified using another code.
- Patients who have been immunized may be tested for immunity by HbsAb monthly until the test indicates immunity (above 10 i.u.). Afterwards, testing for HbsAg or HbsAb may be done only annually under 585.
- Patients who have been vaccinated but do not show immunity are to be treated the same as patients who have not been immunized as in paragraph 1.).
- As always, hepatitis B tests in excess of the 585 frequency may be ordered if separately and individually justified.
- The conclusion from these rules is that hepatitis B testing is to be done on an individual basis, patient by patient, and cannot be on a blanket standing order, since within each center patients will fall into different categories.
- Since there was no rule in effect relating to hepatitis A tests when the HCFA rules were promulgated, such tests can be ordered if separately justified. It is not clear to what extent 585 constitutes a justification; more likely some aspect of liver disease would be required.
- Much more important is the antibody test for hepatitis C, a disease which is many times more prevalent among dialysis patients than hepatitis B. This test was non-existent when the HCFA rules were promulgated and they have never been officially updated. Custom and practice seems to have allowed hepatitis C testing at reasonable intervals (usually quarterly) under 585, but there is no certainty that another code might be demanded in the future, even retroactively. In fact, since no vaccine against hepatitis C exists, it would probably be medically prudent to test previously negative patients at more frequent intervals than quarterly. Once a patient has been found to be positive, he will probably remain so for years at least, since the test does not distinguish the IgG from the IgM antibodies. Even the confirmatory tests which supposedly indicate the presence of active disease are likely to give little additional information in many or most cases, since the disease is so subject to long chronicity. Presumably, the presence of significant active disease can be monitored by analysis of liver enzymes, and then a code of liver disease will be appropriate.
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