The right CPT code for hepatitis C screening depends on who pays the claim. For most commercial plans, you report CPT 86803, the hepatitis C antibody test. For a Medicare screening benefit, you report HCPCS G0472 for an antibody screen or G0567 for an RNA screen, because CMS told its contractors that 86803 doesn’t fit that benefit.
Some Medicaid programs and commercial payers mirror Medicare and ask for G0472 too, so verify the payer’s rule first. That payer split trips up a lot of screening claims.
This guide gives you the code for each scenario, the diagnosis codes that support it, the Medicare frequency rules, and the denial patterns worth checking before you submit. We built it from CMS billing transmittals, the CMS coverage database, and the USPSTF and CDC recommendations, all reviewed in October 2026.
Hepatitis C screening codes at a glance
Coding requirements can vary by payer and patient circumstances. Verify current payer guidance before submitting a claim.
What is the CPT code for hepatitis C screening?
No single code covers every screening claim. CPT, which the American Medical Association maintains, gives you 86803 for the antibody test. CMS maintains HCPCS Level II, which adds G0472 and G0567 for Medicare screening.
So when someone searches for the cpt code for hepatitis c screening, 86803 is the answer outside Medicare, and a G code is the answer inside it. The hepatitis C screening CPT code you pick also depends on the method, because an antibody test and an RNA test carry different codes.
Watch your sources, too. Some low-quality code lists online show 86850 and 86860 as hepatitis C antibody codes. Those two codes describe red blood cell antibody work in transfusion medicine and have nothing to do with HCV. Check every code against the current CPT manual, an AAPC or AMA tool, or a CMS file before it lands on a claim.
How does the hepatitis C antibody screening CPT code (86803) work?
CPT 86803 reports a hepatitis C antibody test that returns a qualitative or semiquantitative result. That covers the standard lab immunoassay and rapid antibody tests. You report one unit per test, and you add 36415 when your staff draws the blood.
Three details cause most of the trouble with the hepatitis C antibody screening CPT code:
- A reactive result doesn’t confirm active infection. Antibodies stay in the blood after the virus clears, so CDC guidance and the lab workflow send a reactive result on to HCV RNA testing.
- A negative result soon after exposure can mislead, because antibodies may take weeks to months to appear.
- CPT 80074, the acute hepatitis panel, already contains the HCV antibody test. If you bill the panel, don’t add 86803 for the same specimen.
Rapid point-of-care tests add one more check. Some payers expect modifier QW on CLIA-waived tests, so confirm the rule before you build the charge. For a refresher on how procedure and diagnosis codes pair on one claim, see how ICD-10 and CPT codes work together.
When should you bill G0472 instead of 86803?
Bill G0472 when a Medicare beneficiary receives an antibody screen under the Medicare hepatitis C screening benefit. CMS created the code for National Coverage Determination 210.13, which took effect for services on or after June 2, 2014. The NCD covers three situations today:
- An initial screen for adults at high risk, defined as current or past injection drug use, or a blood transfusion before 1992.
- A single screen for adults born from 1945 through 1965 who don’t meet the high-risk definition.
- An annual repeat screen only for people with continued injection drug use since their last negative test.
Each situation needs its own code pairing. Swap G0567 in for G0472 when the screen is an RNA test.
Verify eligibility, medical necessity, diagnosis coding, and current Medicare coverage requirements before submitting a claim.
Medicare doesn’t apply the deductible or coinsurance to these lines, but its edits do check where and by whom the service happens. Part B accepts the screen in places of service 11, 22, 49, 50, 71, 72, and 81 when a primary care practitioner orders it, and institutional claims need bill type 13X, 14X, or 85X, per CMS transmittal 13244.
The NCD describes a test ordered in a primary care setting. A hepatology or GI practice that orders the test as part of a diagnostic workup may fall outside the screening benefit, so ask your Medicare Administrative Contractor how to report it.
What is HCPCS G0567, and does it replace G0472?
No. G0567 adds an option and replaces nothing. CPT 87521 describes a newly FDA-approved HCV RNA test, but the CPT code doesn’t say whether a test serves screening or diagnosis. CMS created G0567 to flag RNA tests used for screening under the NCD, effective for dates of service on or after June 27, 2024.
Three billing rules matter:
- CMS applies the same coverage and frequency edits to G0567 that it applies to G0472, so confirm with your contractor before you bill both for one beneficiary.
- Deductible and coinsurance don’t apply to G0567 lines, just as they don’t for G0472.
- A CLIA-waived lab must append modifier QW to G0567. A non-waived lab reports it without the modifier.
Protect Every Claim From Billing Errors
Hepatitis C screening claims fail on small details, such as a payer-specific code, a missing diagnosis pairing, or a frequency edit nobody checked. Docscare’s coding support for lab and screening claims matches each test to the right CPT or HCPCS code before submission, which improves coding accuracy and cuts avoidable rework. Talk with our team about your screening workflow.
Which CPT codes cover follow-up testing after a reactive screen?
A reactive antibody result moves the patient from screening to diagnosis, and the codes change with it. The hepatitis C screening test CPT code stops at the antibody result. The usual next step is an HCV RNA test, and the lab reports that work with one of these codes:
Code selection should reflect the test methodology, documented clinical purpose, and current payer requirements.
Payers differ on which diagnosis code follows a reactive screen, so check the payer’s laboratory policy. Once infection is confirmed, B18.2 reports chronic viral hepatitis C.
Which ICD-10 codes support hepatitis C screening claims?
- Z11.59 reports an encounter for screening for other viral diseases. Use it for asymptomatic patients, and Medicare requires it for the birth-cohort screen.
- Z72.89 reports other problems related to lifestyle. Medicare requires it for high-risk screens.
- F19.20 reports other psychoactive substance dependence, uncomplicated. Medicare pairs it with Z72.89 for the annual repeat.
- B18.2 reports chronic viral hepatitis C, and it belongs on diagnostic claims after confirmation.
- Z20.5 reports contact with and suspected exposure to viral hepatitis, which can support diagnostic testing after a known exposure.
Use a screening code only when the patient has no symptoms and no known infection. If the patient has symptoms or abnormal liver tests, the test is diagnostic, and a screening code would misstate the reason for the service.
Who qualifies for hepatitis C screening coverage in 2026?
Clinical guidance has moved ahead of Medicare. The USPSTF gives a Grade B recommendation for screening all adults aged 18 to 79 without known liver disease, including pregnant people. CDC goes further: at least one lifetime screen for every adult 18 and older, plus a screen during each pregnancy.
A Grade B recommendation triggers the Affordable Care Act preventive services requirement, so non-grandfathered private plans cover the screen without patient cost sharing when the patient uses an in-network provider. Some payers ask for modifier 33 or a specific screening diagnosis, so read the payer’s policy. Medicaid coverage varies by state.
Medicare hasn’t caught up. NCD 210.13 still follows the 2014 criteria. CMS opened a reconsideration on September 23, 2026 to examine screening for adults aged 18 to 79, with public comment through October 23, 2026 and a proposed decision memo due March 23, 2027. Until CMS finalizes a change, a 40-year-old Medicare beneficiary with no risk factor falls outside the benefit.
Watch for a new CMS change request after any final decision, because the billing instructions may change with it.
Why do hepatitis C screening claims get denied?
Most denials trace back to a mismatch between the code, the diagnosis, the patient group, or the setting. Check these seven triggers before you release a claim:
Review current Medicare guidance, laboratory certification requirements, payer edits, and the patient’s documented eligibility before submitting or correcting a claim.
Fixing a denial once helps. Turning it into a charge-entry or registration edit helps every claim after it, and that pattern tracking is the core of denial management services.
How does hepatitis C screening fit into hepatology billing?
For a hepatology practice, a screening claim is rarely the end of the story. It’s the front door. A reactive result usually leads to RNA testing, genotype, fibrosis staging, and treatment visits, and each step changes the coding rules. Staging may involve liver elastography (CPT 91200) alongside evaluation and management visits, and each of those claims carries its own documentation needs.
Our guide to hepatology billing services shows how those claims connect from referral to treatment. Practices that hand off the whole chain, from charge entry to payer follow-up, often rely on outsourced medical billing support to keep screening, diagnostic, and treatment claims consistent across payers.
What should you document for a hepatitis C screening claim?
- The order, with the practitioner’s name and the screening indication.
- The risk factor or birth year that supports the Medicare patient group.
- The test performed, the method, and the lab’s CLIA status.
- The date of the last negative screen, for any repeat claim.
- The result and the follow-up plan, including the RNA order when the antibody result is reactive.
- The payer check: benefit verified, CPT versus HCPCS choice confirmed, and diagnosis linked to the right line.
That last check decides whether the claim passes on the first try. For the metrics behind first-pass success, read what counts as a clean claim.
Frequently asked questions about hepatitis C screening codes
What is the CPT code for hepatitis C antibody screening?
CPT 86803 reports a qualitative or semiquantitative hepatitis C antibody test and works for most commercial claims. Medicare screening claims use HCPCS G0472 instead, with a screening or risk diagnosis such as Z11.59 or Z72.89. Confirm the payer’s rule before you submit.
Is G0472 a CPT code?
No. G0472 is a HCPCS Level II code that CMS maintains, while CPT codes come from the American Medical Association. Both appear on the same claim form, so teams often treat them as one set, but the payer rules for each differ.
What ICD-10 code do I use for hepatitis C screening?
Z11.59, encounter for screening for other viral diseases, covers asymptomatic screening. Medicare also requires Z72.89 for high-risk screens, plus F19.20 for an annual repeat. If the patient has symptoms or a known infection, the test is diagnostic and a screening code doesn’t apply.
How often does Medicare cover hepatitis C screening?
Medicare covers one screen for adults born from 1945 through 1965 who aren’t high risk, an initial screen for high-risk adults, and an annual repeat for people with continued injection drug use. Eleven full months must pass after the month of the last negative test.
Does Medicare cover hepatitis C screening for all adults aged 18 to 79?
Not yet. NCD 210.13 still uses the 2014 criteria. CMS opened a reconsideration on September 23, 2026 to examine screening for adults aged 18 to 79, and its tracking sheet lists a proposed decision memo due date of March 23, 2027.
Which CPT codes report an HCV RNA test?
CPT 87520 reports detection by direct probe, 87521 reports detection by amplified probe, and 87522 reports quantification. For a Medicare screening RNA test, report HCPCS G0567 instead of 87521.
Can I bill 86803 with an acute hepatitis panel?
Not for the same specimen. CPT 80074, the acute hepatitis panel, already includes the hepatitis C antibody test, so adding 86803 duplicates the service.
The short version
Use 86803 for antibody screening with payers that follow CPT. Use G0472 or G0567 for Medicare screening, with the diagnosis codes and frequency rules above. Switch to RNA codes and diagnostic ICD-10 codes once a result is reactive. And keep an eye on CMS, because the Medicare criteria may widen after the 2026 reconsideration.
BILLING PATH
A positive screen starts a longer billing path, from RNA testing to specialist visits. Docscare’s AAPC-certified coders work across specialties, including hepatology, and the team reports a 99% clean claim rate that supports faster reimbursement. If you want a second set of eyes on your screening claims, talk through your screening claims with our team.
