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OA ADAP Allowable PrEP Related Medical Services List

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Allowable Pre-Exposure Prophylaxis (PrEP) Related Medical Services

Effective October 18, 2022

The California Department of Public Health, Office of AIDS (OA), PrEP Assistance Program (PrEP-AP) provides assistance with medical out-of-pocket costs for clients for the PrEP-related services identified below. For reimbursement, all claims must include: 1) a CPT code indicating the procedure or counseling session received, and 2) the ICD-10 code(s) substantiating the reason for the provider visit as being PrEP-related.

Please Note: Reimbursement rates identified in the right column apply to rates paid to contracted providers in the PrEP-AP Provider Network to provide services to uninsured clients. Uninsured clients must receive services at approved locations within the PrEP-AP Provider Network. Clients with insurance will have the actual portion of their co-payment obligation charged by the insurance plan paid for by the PrEP-AP.

Office Visit – Outpatient Service – Medication Administration

CPT Codes	Description	CDPH Reimbursement Rate
99202	New Patient Office or Other Outpatient Service (20 minutes)	$74.06
99203	New Patient Office or Other Outpatient Service (30 minutes)	$113.85
99204	New Patient Office or Other Outpatient Service (45 minutes)	$169.57
99205	New Patient Office or Other Outpatient Service (60 minutes)	$224.25
99211	Established Patient Office or Other Outpatient Service (5 minutes)	$23.53
99212	Established Patient Office or Other Outpatient Service (10 minutes)	$57.45
99213	Established Patient Office or Other Outpatient Service (15 minutes)	$92.05
99214	Established Patient Office or Other Outpatient Service (25 minutes)	$129.77
99215	Established Patient Office or Other Outpatient Service (40 minutes)	$183.07
90471	Immunization Administration	$16.96
96372	Therapeutic, Prophylactic, & Diagnostic Injections and Infusions	$14.54
96373	Therapeutic, Prophylactic, & Diagnostic Injections and Infusions	$18.34
99421	Online Digital Evaluation and Management Service (5-10 minutes)	$15.23
99422	Online Digital Evaluation and Management Service (11-20 minutes)	$29.76
99423	Online Digital Evaluation and Management Service (21 or more minutes)	$48.45
99441	Audio-only (Telephone) Evaluation and Management Service (5-10 minutes)	$56.75
99442	Audio-only (Telephone) Evaluation and Management Service (11-20 minutes)	$91.71
99443	Audio-only (Telephone) Evaluation and Management Service (21-30 minutes)	$129.77
98970	Qualified Nonphysician Health Care Professional Online Digital Evaluation and Management Service (5-10 minutes)	$11.77
98971	Qualified Nonphysician Health Care Professional Online Digital Evaluation and Management Service (11-20 minutes)	$20.79
98972	Qualified Nonphysician Health Care Professional Online Digital Evaluation and Management Service (21-30 minutes)	$32.18
G2012	Brief Communication Technology-based Service (5-10 minutes)	$14.54
G2010	Remote Evaluation of Recorded Video and/or Images Submitted by an Established Patient	$12.11
G2250	Remote Evaluation of Recorded Video and/or Images Submitted by an Established Patient	$12.11
G2251	Brief Communication Technology-based Service (5-10 minutes)	$14.54
G2252	Brief Communication Technology-based Service (11-20 minutes)	$28.03

HIV Testing

CPT Codes	Description	CDPH Reimbursement Rate
85025	Complete Blood Cell Count (red cells, white blood cells, platelets), Automated	$7.77
85026	Complete Blood Cell Count (red cells, white blood cells, platelets), Automated	$7.77
85027	Complete Blood Cell Count (red cells, white blood cells, platelets), Automated	$6.47
86359	CD4 Cell Count	$37.73
86689	HTLV/HIV Confirmatory Test	$19.35
86701	HIV-1	$8.89
86702	HIV-2	$13.52
86703	HIV-1/HIV-2, Type Diffrentiating Assay (Bio Rad Geenius)	$13.71
87389	HIV-1/2 Antigen and Antibodies, Fourth Generation with Reflexes	$24.08
87390	HIV-1 AG, EIA	$24.06
87391	HIV-2 AG, EIA	$21.90
87534	HIV-1, DNA, DIR Probe	$21.92
87535	HIV-1, RNA, Qualitative, PCR	$35.09
87536	HIV-1, Viral Load (RNA, Quant)	$85.10
87537	HIV-2, DNA, DIR Probe	$21.92
87538	HIV-2, DNA, AMP Probe	$35.09
87539	HIV-2, DNA, Quant	$58.62
87806	HIV-1 Antigen and Antibodies, with HIV 1/2 Atibodies	$32.77
87900	HIV-1 Drug Resistance Assay - Phenotype Prediction Using Genotype Bioinformatics	$130.35
87901	HIV-1 Drug Resistance Assay - Protease and Reverse Trascriptase Genotype	$257.45
87906	HIV-1 Drug Resistance Assay - Integrase Genotype	$128.73

STI Testing

CPT Code	Description	CDPH Reimbursement Rate
86592	Blood Serology, Qualitative (Including Non-Treponemal Syphilis Tests (RPR, VRDL)	$4.27
86593	Blood Serology, Quantitative (Including RPR and VRDL Titers)	$4.40
86780	Syphilis Immunoassays (Including T. Pallidum Antibody and the TPPA Assay)	$13.24
87070	Culture, Bacteria, Other	$8.62
87081	Culture	$6.63
87110	Chlamydia, Culture	$19.60
87164	Dark Field without Specimen Collection	$10.74
87166	Dark Field with Specimen Collection	$11.30
87205	Smear Gram Stain	$4.27
87270	Chlamydia Trachomatis AG, IF	$11.98
87285	Treponem Pallidum AG, IF	$12.18
87320	Chlamydia Trachomatis AG, EIA	$15.00
87490	Chlamydia Trach, DNA DIR Probe	$22.75
87491	Chlamydia Trach, DNA AMP Probe	$35.09
87492	Chlamydia DNA or RNA, Quant	$53.47
87590	N. Gonorrhoeae, DNA, DIR Probe	$26.88
87591	N. Gonorrhoeae, DNA, AMP Probe	$35.09
87592	N. Gonorrhoeae, DNA, Quant	$42.84
87593	Orthopoxvirus (e.g., MPX virus, cowpox virus, vaccinia virus), DNA or RNA AMP Probe	$35.09
87800	Smear Gram Stain	$43.67
87801	Multiple Organism NAAT	$70.20

Pregnancy Testing

CPT Code	Description	CDPH Reimbursement Rate
81025	hCG, Qualitative, Urine	$8.61
84702	hCG Beta Subunit, Total, Quantitative, Serum	$15.05
84703	hCG Beta Subunit, Qualitative	$7.52
84704	hCG Free Beta Chain Test	$15.29

Renal Function Testing

CPT Code	Description	CDPH Reimbursement Rate
80053	Comprehensive Metabolic Panel	$10.56
82565	Creatinine, Blood	$5.12
82570	Creatinine, Blood	$5.18
82575	Creatinine, Blood	$9.46

Hepatitis A Screening

CPT Code	Description	CDPH Reimbursement Rate
86708	HAV AB	$12.39

Hepatitis B Screening

CPT Code	Description	CDPH Reimbursement Rate
80074	Acute Hepatitis Panel	$47.63
86705	Hepatitis B Core Antibody (IGM) Measurement	$11.77
86706	HBV Surface AB	$10.74
87340	Hepatitis B Surface AG, EIA	$10.33
87341	Hepatitis B Surface AG, Immunoassay	$10.33
87350	Detection Test by Immunoassay	$11.53
86704	HBV Core AB	$12.05

Hepatitis C Screening

CPT Code	Description	CDPH Reimbursement Rate
86803	Hepatitis C AB Test	$14.27
86804	Hepatitis C AB Test, Confirm	$15.49
87522	Hepatitis C Viral RNA, Quantitive, Real-Time PCR	$42.84

Liver Function Test

CPT Code	Description	CDPH Reimbursement Rate
84460	Transferase Alanine Amino ALT SGPT	$5.30

Cholesterol and Triglyceride Screening

CPT Code	Description	CDPH Reimbursement Rate
80061	Lipid Panel	$13.39
82465	Cholesterol, Total	$4.35
83718	Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)	$8.19
83719	Lipoprotein, direct measurement; very low density cholesterol (VLDL cholesterol)	$12.75
83721	Lipoprotein, direct measurement; low density cholesterol (LDL cholesterol)	$10.50
84478	Triglycerides	$14.27

Other

CPT Code	Description	CDPH Reimbursement Rate
36415	Collection Venous Blood Venipuncture	$3.00
81001	Urinalysis; automated, with microscopy	$3.17

PrEP Related ICD-10 Codes

ICD-10 CODE	DESCRIPTION
Z71.7	Encounter for HIV Counseling
Z72.5	High-Risk Sexual Behavior
Z72.51	High-Risk Heterosexual Behavior
Z72.52	High-Risk Homosexual Behavior
Z72.53	High-Risk Bisexual Behavior
Z20	Contact with and (Suspected) Exposure to Communicable Disease
Z20.2	Contact with and (Suspected) Exposure to Infections with a Predominantly Sexual Mode of Transmission
Z20.5	Contact with and (Suspected) Exposure to Viral Hepatitis
Z20.6	Contact with and (Suspected) Exposure to Human Immunodeficiency Virus (HIV)
Z20.8	Contact with and (Suspected) Exposure to Other Communicable Diseases
Z20.82	Contact with and (Suspected) Exposure to Other Viral Communicable Diseases
Z20.81	Contact with and (Suspected) Exposure to Other Bacterial Communicable Diseases
Z20.9	Contact with and (Suspected) Exposure to Unspecified Communicable Diseases
Z29.8	Other Specified Prophylactic Measures
Z771.21	Contact with and (Suspected) Exposure to Potentially Hazardous Body Fluids
W46.0XXA	Contact with Hypodermic Needle (Initial Encounter)
W46.0XXD	Contact with Hypodermic Needle (Subsequent Encounter)
W46.1XXA	Contact with Contaminated Hypodermic Needle (Initial Encounter)
W46.1XXD	Contact with Contaminated Hypodermic Needle (Subsequent Encounter)
Z11.59	Encounter for Other Viral Diseases
Z70.0	Counseling Realted to Sexual Attitude
Z70.1	Counseling Related to Patients Sexual Behavior and Orientation
Z11.4	Encounter for Screening for Human Immunodeficiency Virus (HIV)
Z11.3	Encounter for Screening for Infections with a Predominantly Sexual Mose of Transmission
Z01.812	Encounter for Preprocedural Laboratory Examination
Z51.81	Encounter for Therapeutic Drug Level Monitoring
Z79.899	Other Long Term (Current) Drug Therapy