LGBTQ Agenda: 22 AGs ask CDC to make new PrEP billing code to avoid erroneous copays

  • by John Ferrannini, Assistant Editor
  • Tuesday March 14, 2023
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Nearly two-dozen attorneys general have signed on to a letter asking the CDC to create a separate billing code for PrEP, of which Truvada is one such medication, so that people don't receive erroneous copays.
Nearly two-dozen attorneys general have signed on to a letter asking the CDC to create a separate billing code for PrEP, of which Truvada is one such medication, so that people don't receive erroneous copays.

Attorneys general from 21 states, including California, and the District of Columbia, signed on to a letter to a U.S. Centers for Disease Control and Prevention committee asking it to create a new diagnostic code for PrEP to ensure clear billing.

The attorneys general want to make sure that people who take the HIV prevention medication are not improperly charged copays, the letter states. Under federal law, insurers must fully cover PrEP.

California Attorney General Rob Bonta (D) tweeted about his sign-on March 2.

"I'm joining 22 AGs in supporting action to increase accessibility and affordability of PrEP — a critical medication that keeps people safe from HIV and saves lives," Bonta stated. "My office will always fight to increase access to lifesaving medication for all who need it."

PrEP, or pre-exposure prophylaxis, refers to the use of antiviral drugs to prevent people exposed to HIV from becoming infected. The pill Truvada was first approved for PrEP use in 2012 by the federal Food and Drug Administration; since then the FDA has also approved the pill Descovy for some groups, and the drug Apretude as an injectable treatment. According to CDC statistics, only 25% of the approximately 1.2 million Americans who could benefit from PrEP had prescriptions in 2020.

As the Bay Area Reporter has previously reported, people of color continue to experience access issues regarding PrEP and having insurance cover the medication is viewed as one way to reduce those disparities.

The letter was drafted by Massachusetts Attorney General Andrea Joy Campbell (D) and was sent March 1 from the attorneys general to the coordination and maintenance committee of the CDC's National Center for Health Statistics.

It asks for a change to the International Classification of Diseases, 10th Revision (ICD-10) — a three-volume medical text used by doctors to classify and code all medical diagnoses, symptoms, and claims processing — so that PrEP has its own diagnostic code. This would ensure PrEP users are not improperly charged copays.

"Establishing an ICD-10 code for PrEP would create clarity," the letter states. "Currently, there is no specific ICD-10 diagnosis code for PrEP. Instead, providers have a range of less specific options available to them. As such, not only are insurers and providers unsure which code is most appropriate for PrEP, the codes do not apply to solely PrEP, making it difficult for providers to indicate that the service is preventative and covered without cost sharing."

The lack of a code means that medical procedures can be subject to copays by mistake.

"For example, a patient hoping to receive PrEP might be required to take a pregnancy test prior to prescription," the letter states. "Without an ICD-10 code to indicate the pregnancy test is for PrEP and is therefore preventative, there is no way to ensure the service is billed properly across providers and third-party vendors (such as laboratories) or covered consistently by insurers."

PrEP should be covered by insurers at no cost, due to it being preventative care under the Patient Protection and Affordable Care Act.

"Under the Affordable Care Act, preventative services, such as PrEP, should be covered at no cost to the patient," the letter states. "However, several states have received complaints from patients who have been charged copays for covered PrEP-related services in violation of the Affordable Care Act. One patient in Massachusetts reported having been billed over eight hundred dollars for laboratory testing that was required for the patient to receive PrEP. Other patients reported smaller bills, but even a copay of fifteen dollars can deter patients with limited resources from seeking care."

Carl Schmid, a gay man who is the executive director of the HIV+Hepatitis Policy Institute, worked with Campbell's office on drafting the letter.

"Through their [the Massachusetts' AG's office] investigation and others, correct use of billing codes for PrEP has been identified as a barrier. There are several codes providers can use and insurers have not stepped up to solve this problem," Schmid stated.

"Having a standard billing code, as has been requested by the 22 attorneys general, should help alleviate these problems," he added. "We understand that the CDC had already begun the process, but the letter will add pressure on them to make sure it will happen."

Schmid stated to the B.A.R. that "insurers need to get their act together."

"PrEP and its associated services are supposed to be free to people with insurance. We need to make sure that anyone who wants PrEP can get it easily," Schmid stated. "Unfortunately, implementation has not gone smoothly. ... We are glad that the attorneys general, who are charged with reviewing for violations of the law, are on top of it."

In addition to Massachusetts, California, and Washington, D.C., the other attorneys general who signed the letter are from Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Washington, Wisconsin, and Vermont.

Lisa George, a public affairs specialist with the media relations division of the CDC, stated to the B.A.R. that "A full official list of new ICD-10-CM codes and changes, which is still being completed, is scheduled to go into effect in early October 2023."

When asked if this means PrEP will have the new code, as asked for in the letter, George replied that the provided statement is "all I have."

LGBTQ Agenda is an online column that appears weekly. Got a tip on queer news? Contact John Ferrannini at [email protected]

Updated: 3/14/23: This article has been updated with comments from the CDC.

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