Medicare pays for hepatitis C screening under National Coverage Determination (NCD) 210.13. You bill it with HCPCS G0472 for an antibody screen or G0567 for an RNA screen, and the patient owes no deductible or coinsurance. Payment depends on three things lining up: the patient belongs to a covered group, a primary care practitioner ordered the test, and the claim carries the right diagnosis, place of service, and frequency history.
This guide to billing Medicare for hepatitis C screening follows one claim from eligibility check to denial rework. We built it from CMS manuals, transmittals, and the Medicare Coverage Database, and we reviewed each rule in October 2026. It covers Original Medicare (Part B). Medicare Advantage plans run their own claim edits, so confirm their rules separately.
One timing note before you start: CMS opened a review of this NCD on September 23, 2026, and public comment runs through October 23. The coverage rules below still apply today.
What does Medicare cover for hepatitis C screening?
Medicare covers hepatitis C virus (HCV) screening with FDA-approved or cleared laboratory tests, performed in line with CLIA rules, when the beneficiary’s primary care physician or practitioner orders the test in a primary care setting. Coverage applies to services on or after June 2, 2014, and the rules sit in NCD 210.13.
Three patient groups qualify. The table shows what the Medicare contractor looks for on the claim and what your chart needs to back it up.
Everyone else falls outside the benefit. A patient born in 1964 qualifies today. A patient born in 1971 with no documented risk factor doesn’t, even though the U.S. Preventive Services Task Force recommends screening all adults aged 18 to 79. Medicare’s rules haven’t caught up with that recommendation yet, and the pending review gets its own section below.
Who can order the test, and where can you bill it?
CMS checks the ordering provider and the setting before it looks at anything else. Get either wrong and the claim denies, no matter how clean the codes are. The NCD is built around primary care, so a primary care office is the natural home for the order.
Ordering provider. Professional claims pay only when the order comes from a provider whose enrollment record shows one of ten specialties: general practice, family practice, internal medicine, obstetrics/gynecology, pediatric medicine, geriatric medicine, certified nurse midwife, nurse practitioner, certified clinical nurse specialist, or physician assistant. The edit reads the specialty on the enrollment record, not the provider’s job title. Gastroenterology isn’t on the list, so an order that starts in a GI or liver practice can fail unless the ordering provider is enrolled under a listed specialty. That edit deserves a place in your claim scrubber, because it depends on enrollment data rather than anything you type on the claim.
Setting. Professional lines need a listed place of service (POS). Institutional claims need a listed type of bill (TOB). Hospital outpatient departments get no exemption: the same primary care order requirement applies there.
Should you bill G0472 or G0567?
Pick the code by test method. G0472 reports a hepatitis C antibody screen. G0567 reports a nucleic acid (RNA) screen by amplified probe technique, and it applies to dates of service on or after June 27, 2024. CMS applies the same coverage and frequency edits to both. CMS tells providers to report the HCPCS codes for this benefit, so CPT 86803 doesn’t belong on a Medicare screening line. Commercial payers differ, and our guide to hepatitis C screening codes by payer covers those.
Modifier QW needs care on G0567. CMS pays the code with QW when a CLIA-waived laboratory bills it and without QW when a non-waived laboratory bills it, retroactive to June 27, 2024. CMS announced that clarification in February 2026 through an MLN Connects message, and it states that policy didn’t change. Your Medicare Administrative Contractor (MAC) adjusts claims you bring to its attention, so pull any G0567 claims since mid-2024 that denied or paid incorrectly over QW status and send them back. Labs that bill their own screens should also review billing for in-house labs against the same rule.
Whichever code you bill, deductible and coinsurance don’t apply to the line.
Which diagnosis codes go with each patient group?
The diagnosis tells Medicare’s edits which frequency limit to apply, so it has to match the reason you documented.
- Z11.59 (encounter for screening for other viral diseases) for the 1945 through 1965 birth group.
- Z72.89 (other problems related to lifestyle) for high-risk adults, including the first screen.
- Z72.89 plus F19.20 (other psychoactive substance dependence, uncomplicated) for the annual repeat after continued injection drug use.
If none of those codes appears and the patient was born before 1945 or after 1965, the claim denies as non-covered. Use screening diagnoses only when the patient has no symptoms and no known hepatitis C. Symptoms or abnormal liver tests make the test diagnostic, and a screening code would misstate why you ran it.
Protect Every Claim From Errors
Ordering and setting errors can sink a screening claim even when the coding is right. Our billing support for liver practices reviews each claim before it goes out, which helps reduce claim denials. Talk with our team about how your practice handles screening orders and eligibility checks.
How do you check frequency before you collect the specimen?
The annual rule is easy to miscount. CMS requires a full 11 months to pass after the month of the last negative screen. If the last negative result came in March 2026, the patient becomes eligible again in March 2027, because April 2026 through February 2027 are the 11 full months in between.
The lifetime limit for the 1945 through 1965 group has a different trap: you can’t see screens that another practice, lab, or hospital billed. Run eligibility before the draw, and ask your clearinghouse or MAC portal how it displays prior HCV screening dates. CMS revised its HETS eligibility coding for this NCD in June 2025, so confirm your tool reflects it. When the system can’t answer, ask the patient and record the answer.
Decide on an advance beneficiary notice (ABN) before the service, not after the denial. When a claim goes out with modifier GZ, meaning no signed ABN is on file, the denial carries group code CO and the liability stays with your practice. CMS also marks several of these edits as overridable, so a corrected claim with supporting documentation can still pay. Check your MAC’s guidance on ABNs for screening services.
What do Medicare’s hepatitis C denial codes mean?
CMS publishes the denial messages for this benefit in Chapter 18, section 210.3 of the Medicare Claims Processing Manual. Match the CARC and RARC pair on your remittance to the edit that fired, then fix the cause upstream instead of just resubmitting. A denial management process that logs each pair shows which front-end step keeps failing.
What changed in 2026, and what could change next?
- February 2026: CMS clarified that G0567 is payable with or without QW depending on the laboratory’s CLIA status, retroactive to June 27, 2024 (transmittal R13633OTN, change request 14388).
- March 26, 2026: CMS reissued Chapter 18, sections 210 through 210.4, to add G0567 to the professional and institutional rules (transmittal R13680CP, change request 14408). The manual lists an effective date of October 1, 2025 and an implementation date of July 6, 2026.
- September 23, 2026: CMS opened a national coverage analysis to reconsider NCD 210.13 for adults aged 18 to 79, after five formal requests that included Quest Diagnostics, the American College of Obstetricians and Gynecologists, and a hospital revenue cycle team.
CMS asked commenters for evidence on screening intervals for people who stay at risk and on screening in non-primary care settings. The second question matters to specialist and laboratory workflows, though CMS hasn’t said how it will rule. The agency lists a proposed decision memo for March 23, 2027 and expected completion for June 21, 2027. Until a final NCD and a new change request arrive, the rules in this guide stay in force. When coverage widens, expect new age and diagnosis edits in your claim scrubber.
How does this affect hepatology and laboratory billing?
A hepatitis C screen often starts a longer billing path. A reactive antibody result moves the patient from screening to diagnosis, and the claim rules change with it. Diagnostic testing needs a medical-necessity diagnosis, and the deductible and coinsurance waiver tied to G0472 and G0567 no longer applies. Specialists also meet the ordering rule head-on, because the benefit assumes a primary care order. The claims that follow a reactive screen, from elastography to biopsy and lab panels, carry their own coding rules, and our hepatology billing work covers them.
Laboratories carry two extra variables: QW status on G0567 and bill type 14X for non-patient specimens. Get both right before the claim leaves your system.
What belongs on your pre-bill checklist?
- Confirm the patient’s birth year and the risk factor documented in the chart.
- Run eligibility and check prior screening history before you collect the specimen.
- Confirm the ordering provider’s enrolled specialty appears on the CMS list.
- Match the code to the test method, and add QW to G0567 only for CLIA-waived laboratories.
- Attach Z11.59, Z72.89, or Z72.89 plus F19.20 to match the patient group.
- Verify POS 11, 19, 22, 49, 71, or 81 on professional claims, or TOB 13X, 14X, or 85X on institutional claims.
- For a repeat screen, count 11 full months from the month of the last negative result.
- Decide on an ABN before service when a frequency or coverage denial looks likely.
Build these checks into charge entry and registration so errors stop before submission. Medical coding support can review your screening claims against this list. Track each CARC and RARC pair you receive, so repeat failures point to the step that needs a fix.
Medicare hepatitis C screening billing FAQs
Does Medicare cover hepatitis C screening for all adults?
No. Medicare covers screening for adults born from 1945 through 1965 and for high-risk adults. A patient outside those groups isn’t covered, even though the USPSTF recommends screening adults aged 18 to 79. CMS opened a review of that gap on September 23, 2026.
How often will Medicare pay for hepatitis C screening?
The 1945 through 1965 group gets one screen per lifetime. High-risk adults get one initial screen. Adults with continued injection drug use since a negative screen get one per year, counted as 11 full months after the month of the last negative result.
Do Medicare patients pay a copay or deductible for the screen?
No. CMS waives the deductible and coinsurance on claim lines with G0472 or G0567. Diagnostic testing falls outside the screening benefit, so the waiver doesn’t apply to it.
Which providers can order a billing Medicare for hepatitis C screening?
Ten enrolled specialties qualify, including family practice, internal medicine, OB/GYN, nurse practitioners, and physician assistants (the full list sits in the ordering section above). Gastroenterology isn’t one of them. The order must also come from a primary care setting, and other specialties deny with CARC 184.
Can a lab bill Medicare for hepatitis C screening directly?
Yes, if an eligible provider placed the order and the claim uses an allowed setting, such as POS 81 for an independent laboratory or bill type 14X for a non-patient specimen. A lab adds modifier QW to G0567 only when the lab is CLIA-waived.
What should I do when Medicare denies a hepatitis C screening claim?
Read the CARC and RARC pair, match it to the edit in the table above, and correct the cause: ordering provider, POS or bill type, diagnosis pairing, or frequency history. Several edits are overridable, so resubmit with supporting documentation. Then fix the upstream step so the next claim passes.
Bottom line
Medicare screening claims pass when five items line up: patient group, ordering provider, code, diagnosis, and setting. Check them in that order, trace every denial back to the step that failed, and watch the open CMS review so your edits can change when coverage does. Practices that would rather hand off claim edits and rework can look at full-service medical billing services instead of building every check in-house.
Protect Every Claim From Errors
Screening denials rarely come from one big mistake. They come from small mismatches between the order, the chart, and the claim, and each one adds rework. Docscare’s Hepatology Billing Services help liver and GI practices improve reimbursement by catching those mismatches before submission. Schedule a consultation to review how your practice bills screening and follow-on claims.
