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July 2019
April 2019

CMS Transmittals

National Coverage Determination
Procedure Code: 8XXXX
Hepatitis Panel/Acute Hepatitis Panel
CMS Policy Number: 190.33
Back to NCD List

Description: This panel consists of the following tests:

  • Hepatitis A antibody (HAAb), IgM antibody;
  • Hepatitis B core antibody (HBcAb), IgM antibody;
  • Hepatitis B surface antigen (HBsAg) and;
  • Hepatitis C antibody.

    Hepatitis is an inflammation of the liver resulting from viruses, drugs, toxins, and other etiologies. Viral hepatitis can be due to one of at least five different viruses, designated hepatitis A, B, C, and E. Most cases are caused by hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis C virus (HCV).

    HAV is the most common cause of hepatitis in children and adolescents in the United States. Prior exposure is indicated by a positive IgG anti-HAV. Acute HAV is diagnosed by IgM anti- HAV, which typically appears within four weeks of exposure, and which disappears within three months of its appearance. IgG anti-HAV is similar in the timing of its appearance, but it persists indefinitely. Its detection indicates prior effective immunization or recovery from infection. Although HAV is spread most commonly by fecal-oral exposure, standard immune globulin may be effective as a prophylaxis.

    HBV produces three separate antigens (surface, core, and e (envelope) antigens) when it infects the liver, although only hepatitis B surface antigen (HBsAg) is included as part of this panel. Following exposure, the body normally responds by producing antibodies to each of these antigens; one of which is included in this panel: hepatitis B surface antibody (HBsAb)-IgM antibody. HBsAg is the earlier marker, appearing in serum four to eight weeks after exposure, and typically disappearing within six months after its appearance. If HBsAg remains detectable for greater than six months, this indicates chronic HBV infection. HBcAb, in the form of both IgG and IgM antibodies, are next to appear in serum, typically becoming detectable two to three months following exposure. The IgM antibody gradually declines or disappears entirely one to two years following exposure, but the IgG usually remains detectable for life. Because HBsAg is present for a relatively short period and usually displays a low titer, a negative result does not exclude an HBV diagnosis. HBcAb, on the other hand, rises to a much higher titer and remains elevated for a longer period of time, but a positive result is not diagnostic of acute disease, since it may be the result of a prior infection. The last marker to appear in the course of a typical infection is HBsAb, which appears in serum four to six months following exposure to infected blood or body fluids; in the U.S., sexual transmission accounts for 30% to 60% of new cases of HBV infection.

    The diagnosis of acute HBV infection is best established by documentation of positive IgM antibody against the core antigen (HBcAb-IgM) and by identification of a positive hepatitis B surface antigen (HBsAg). The diagnosis of chronic HBV infection is established primarily by identifying a positive hepatitis B surface antigen (HBsAg) and demonstrating positive IgG antibody directed against the core antigen (HBcAb-IgG). Additional tests such as hepatitis B e antigen (HBeAg) and hepatitis B e antibody (HBeAb), the envelope antigen and antibody, are not included in the hepatitis panel, but may be of importance in assessing the infectivity of patients with HBV. Following completion of a HBV vaccination series, HBsAb alone may be used monthly for up to six months, or until a positive result is obtained, to verify an adequate antibody response.

    HCV is the most common cause of post-transfusion hepatitis; overall HCV is responsible for 15% to 20% of all cases of acute hepatitis, and is the most common cause of chronic liver disease. The test most commonly used to identify HCV measures HCV antibodies, which appear in blood two to four months after infection. False positive HCV results can occur. For example, a patient with a recent yeast infection may produce a false positive anti-HCV result. For this reason, at present positive results usually are confirmed by a more specific technique. Like HBV, HCV is spread exclusively through exposure to infected blood or body fluids.

    This panel of tests is used for differential diagnosis in a patient with symptoms of liver disease or injury. When the time of exposure or the stage of the disease is not known, a patient with continued symptoms of liver disease despite a completely negative hepatitis panel may need a repeat panel approximately two weeks to two months later to exclude the possibility of hepatitis. Once a diagnosis is established, specific tests can be used to monitor the course of the disease.

    1. To detect viral hepatitis infection when there are abnormal liver function test results, with or without signs or symptoms of hepatitis.

    2. Prior to and subsequent to liver transplantation.

    After a hepatitis diagnosis is established, only individual tests are needed.

    Frequency Limitations: After a hepatitis diagnosis has been established, only individual tests, rather than the entire panel, are needed.

    To review all requirements of this policy, please see: CMS NCD listing by Chapter

    Covered ICD-10 Codes.

    A92.5 Zika virus disease
    B15.0 Hepatitis A with hepatic coma
    B15.9 Hepatitis A without hepatic coma
    B16.0 Acute hepatitis B with delta-agent with hepatic coma
    B16.1 Acute hepatitis B with delta-agent without hepatic coma
    B16.2 Acute hepatitis B without delta-agent with hepatic coma
    B16.9 Acute hepatitis B w/o delta-agent and without hepatic coma
    B17.0 Acute delta-(super) infection of hepatitis B carrier
    B17.10 Acute hepatitis C without hepatic coma
    B17.11 Acute hepatitis C with hepatic coma
    B17.2 Acute hepatitis E
    B17.8 Other specified acute viral hepatitis
    B17.9 Acute viral hepatitis, unspecified
    B18.0 Chronic viral hepatitis B with delta-agent
    B18.1 Chronic viral hepatitis B without delta-agent
    B18.2 Chronic viral hepatitis C
    B18.8 Other chronic viral hepatitis
    B18.9 Chronic viral hepatitis, unspecified
    B19.0 Unspecified viral hepatitis with hepatic coma
    B19.10 Unspecified viral hepatitis B without hepatic coma
    B19.11 Unspecified viral hepatitis B with hepatic coma
    B19.20 Unspecified viral hepatitis C without hepatic coma
    B19.21 Unspecified viral hepatitis C with hepatic coma
    B19.9 Unspecified viral hepatitis without hepatic coma
    F11.11 Opioid abuse, in remission
    F12.93 Cannabis use, unspecified with withdrawal
    F14.11 Cocaine abuse, in remission
    F15.11 Other stimulant abuse, in remission
    G93.3 Postviral fatigue syndrome
    I85.00 Esophageal varices without bleeding
    I85.01 Esophageal varices with bleeding
    I85.10 Secondary esophageal varices without bleeding
    I85.11 Secondary esophageal varices with bleeding
    K70.41 Alcoholic hepatic failure with coma
    K71.0 Toxic liver disease with cholestasis
    K71.10 Toxic liver disease with hepatic necrosis, without coma
    K71.11 Toxic liver disease with hepatic necrosis, with coma
    K71.2 Toxic liver disease with acute hepatitis
    K71.3 Toxic liver disease with chronic persistent hepatitis
    K71.4 Toxic liver disease with chronic lobular hepatitis
    K71.50 Toxic liver disease w chronic active hepatitis w/o ascites
    K71.51 Toxic liver disease w chronic active hepatitis with ascites
    K71.6 Toxic liver disease with hepatitis, not elsewhere classified
    K71.7 Toxic liver disease with fibrosis and cirrhosis of liver
    K71.8 Toxic liver disease with other disorders of liver
    K71.9 Toxic liver disease, unspecified
    K72.00 Acute and subacute hepatic failure without coma
    K72.01 Acute and subacute hepatic failure with coma
    K72.10 Chronic hepatic failure without coma
    K72.11 Chronic hepatic failure with coma
    K72.90 Hepatic failure, unspecified without coma
    K72.91 Hepatic failure, unspecified with coma
    K74.0 Hepatic fibrosis
    K74.60 Unspecified cirrhosis of liver
    K74.69 Other cirrhosis of liver
    K75.0 Abscess of liver
    K75.1 Phlebitis of portal vein
    K75.2 Nonspecific reactive hepatitis
    K75.3 Granulomatous hepatitis, not elsewhere classified
    K75.81 Nonalcoholic steatohepatitis (NASH)
    K75.89 Other specified inflammatory liver diseases
    K75.9 Inflammatory liver disease, unspecified
    K76.2 Central hemorrhagic necrosis of liver
    K76.4 Peliosis hepatis
    K76.6 Portal hypertension
    K76.7 Hepatorenal syndrome
    K76.81 Hepatopulmonary syndrome
    M04.1 Periodic fever syndromes
    R10.0 Acute abdomen
    R10.10 Upper abdominal pain, unspecified
    R10.11 Right upper quadrant pain
    R10.12 Left upper quadrant pain
    R10.13 Epigastric pain
    R10.2 Pelvic and perineal pain
    R10.30 Lower abdominal pain, unspecified
    R10.31 Right lower quadrant pain
    R10.32 Left lower quadrant pain
    R10.33 Periumbilical pain
    R10.811 Right upper quadrant abdominal tenderness
    R10.821 Right upper quadrant rebound abdominal tenderness
    R10.83 Colic
    R10.84 Generalized abdominal pain
    R10.9 Unspecified abdominal pain
    R11.0 Nausea
    R11.10 Vomiting, unspecified
    R11.11 Vomiting without nausea
    R11.12 Projectile vomiting
    R11.14 Bilious vomiting
    R11.2 Nausea with vomiting, unspecified
    R16.0 Hepatomegaly, not elsewhere classified
    R16.2 Hepatomegaly with splenomegaly, not elsewhere classified
    R17 Unspecified jaundice
    R40.2410 Glasgow coma scale score 13-15, unspecified time
    R40.2411 Glasgow coma scale score 13-15, in the field
    R40.2412 Glasgow coma scale score 13-15, EMR
    R40.2413 Glasgow coma scale score 13-15, at hospital admission
    R40.2414 Glasgow coma scale score 13-15, 24+hrs
    R40.2420 Glasgow coma scale score 9-12, unspecified time
    R40.2421 Glasgow coma scale score 9-12, in the field
    R40.2422 Glasgow coma scale score 9-12, EMR
    R40.2423 Glasgow coma scale score 9-12, at hospital admission
    R40.2424 Glasgow coma scale score 9-12, 24+hrs
    R40.2430 Glasgow coma scale score 3-8, unspecified time
    R40.2431 Glasgow coma scale score 3-8, in the field
    R40.2432 Glasgow coma scale score 3-8, EMR
    R40.2433 Glasgow coma scale score 3-8, at hospital admission
    R40.2434 Glasgow coma scale score 3-8, 24+hrs
    R40.2440 Other coma, without Glasgow, or w/part score, unsp time
    R40.2441 Other coma, without Glasgow, or w/part score, in the field
    R40.2442 Other coma, without documented Glasgow, or w/part score, EMR
    R40.2443 Other coma, without Glasgow, or w/part score, admit
    R40.2444 Other coma, without Glasgow, or w/part score, 24+hrs
    R53.0 Neoplastic (malignant) related fatigue
    R53.1 Weakness
    R53.2 Functional quadriplegia
    R53.81 Other malaise
    R53.82 Chronic fatigue, unspecified
    R53.83 Other fatigue
    R56.00 Simple febrile convulsions
    R56.01 Complex febrile convulsions
    R56.1 Post traumatic seizures
    R62.0 Delayed milestone in childhood
    R62.50 Unsp lack of expected normal physiol dev in childhood
    R62.51 Failure to thrive (child)
    R62.52 Short stature (child)
    R62.59 Oth lack of expected normal physiol development in childhood
    R63.0 Anorexia
    R63.1 Polydipsia
    R63.2 Polyphagia
    R63.3 Feeding difficulties
    R63.4 Abnormal weight loss
    R63.5 Abnormal weight gain
    R63.6 Underweight
    R74.0 Nonspec elev of levels of transamns & lactic acid dehydrgnse
    R94.5 Abnormal results of liver function studies
    T86.40 Unspecified complication of liver transplant
    T86.41 Liver transplant rejection
    T86.42 Liver transplant failure
    T86.43 Liver transplant infection
    T86.49 Other complications of liver transplant
    Z01.89 Encounter for other specified special examinations
    Z05.0 Obs & eval of NB for suspected cardiac condition ruled out
    Z05.1 Obs & eval of NB for suspected infect condition ruled out
    Z05.2 Obs & eval of NB for suspected neuro condition ruled out
    Z05.3 Obs & eval of NB for suspected resp condition ruled out
    Z05.41 Obs & eval of NB for suspected genetic condition ruled out
    Z05.42 Obs & eval of NB for suspected metabolic condition ruled out
    Z05.43 Obs & eval of NB for suspected immunologic cond ruled out
    Z05.5 Obs & eval of NB for suspected GI condition ruled out
    Z05.6 Obs & eval of NB for suspected GU condition ruled out
    Z05.71 Obs & eval of NB for suspected skin, subcu cond ruled out
    Z05.72 Obs & eval of NB for suspected ms condition ruled out
    Z05.73 Obs & eval of NB for suspected conn tiss condition ruled out
    Z05.8 Obs & eval of NB for oth suspected condition ruled out
    Z05.9 Obs & eval of NB for unsp suspected condition ruled out
    Z19.1 Hormone sensitive malignancy status
    Z19.2 Hormone resistant malignancy status
    Z29.11 Enctr for prphylc immther for resp syncytial virus (RSV)
    Z84.82 Family history of sudden infant death syndrome

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