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HCPCS G0475 · Level II · G code

G0475: HIV antigen/antibody, combination assay, screening, HCPCS Level II G code

Compiled from CMS files by the QuickIntell RCM Editorial Team · Data effective · Method: reference methodology · Report a data correction

Data currency: HCPCS Level II file: October 2026 (effective October 1, 2026); PFS relative value file: RVU26D, released August 26, 2026 (effective October 1, 2026); Clinical Laboratory Fee Schedule: 26CLABQ4 (CY2026 Q4) (effective October 1, 2026); NCCI MUE tables: 2026 Q4 (effective October 1, 2026); NCCI PTP edits: v323r0 (2026 Q4) (effective October 1, 2026); OPPS Addendum B: October 2026 (effective October 1, 2026). Next CMS release: January 1, 2027 (quarterly update) for the HCPCS Level II file and Clinical Laboratory Fee Schedule and NCCI MUE tables and NCCI PTP edits and OPPS Addendum B; RVU27A with the CY2027 PFS final rule, effective January 1, 2027 for the PFS relative value file.

Key facts for G0475

Medicare payment
$24.08
CLFS national limitation amount
Coverage code
C
carrier judgment, so the Medicare contractor decides coverage
Practitioner MUE
1
MAI 2
OPPS status
SI A
Services not paid under OPPS; paid under fee schedule or other payment system
NCCI PTP pairs
11
11 hospital outpatient
LCDs and articles
0 / 0

TL;DR

HCPCS Level II G0475 reads "Hiv antigen/antibody, combination assay, screening" in the October 2026 file; it dates from 2015. The 2026 Q4 clinical laboratory fee schedule pays G0475 $24.08 (national limitation amount), also listed with QW. CMS caps G0475 at practitioner 1 (MAI 2, CMS Policy); hospital outpatient 1 (MAI 2, CMS Policy) units per day in the 2026 Q4 MUE tables. In the NCCI PTP files v323r0 G0475 appears in 1 practitioner pairs as column 2 and 10 as column 1 (most often with 87806), and in 1 hospital outpatient pairs as column 2 and 10 as column 1. G0475 appears in no active LCD or billing and coding article, so coverage follows HCPCS coverage code C (carrier judgment, so the Medicare contractor decides coverage) and any NCD. OPPS status indicator A: Services not paid under OPPS; paid under fee schedule or other payment system. HCPCS record: BETOS T2D (other tests - other); pricing indicator 13; type of service 5 (diagnostic laboratory). Nearby codes: G0476, G0473, G0472, G0471.

G0475 descriptor and code status

The October 2026 HCPCS Level II file describes G0475 as “Hiv antigen/antibody, combination assay, screening”. It sits in the G section (procedures and professional services, temporary), listed with the other G codes.

HCPCS file attributes of G0475
FieldValue
Short descriptorHiv combination assay
Added to HCPCS2015-04-13
Last actionN (no maintenance), effective 2015-04-13
Coverage codeC: carrier judgment, so the Medicare contractor decides coverage
Pricing indicator13: physician fee schedule, priced by the contractor
BETOS categoryT2D: other tests - other
Type of service5: diagnostic laboratory

Medicare payment for G0475

The 2026 Q4 clinical laboratory fee schedule pays G0475 $24.08 (national limitation amount), also listed with QW. The amounts below are national figures from the October 2026 CMS files; the contractor applies the locality, rural or state adjustment and the beneficiary's cost sharing.

Physician fee schedule (RVU26D)

Status X: statutory exclusion: not a physician service under the fee schedule. Global period XXX (global surgery concept does not apply); PC/TC indicator 9 (professional/technical concept does not apply).

Clinical Laboratory Fee Schedule (26CLABQ4)

G0475 is paid at $24.08 (national limitation amount); the file also lists it with modifier QW (a CLIA-waived test). Laboratory fee schedule payments carry no beneficiary coinsurance or deductible.

Hospital outpatient (OPPS Addendum B)

Status indicator A (Services not paid under OPPS; paid under fee schedule or other payment system), with no separate OPPS payment rate.

Medically Unlikely Edits for G0475

CMS caps G0475 at practitioner 1 (MAI 2, CMS Policy); hospital outpatient 1 (MAI 2, CMS Policy) units per day in the 2026 Q4 MUE tables. The practitioner MUE is a date-of-service policy edit: units above the limit deny even when split across lines, and appeals rarely succeed.

MUE values for G0475 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services12 Date of Service Edit: PolicyCMS Policy
Facility outpatient hospital12 Date of Service Edit: PolicyCMS Policy

The MUE lookup for G0475 shows every setting next to any other code on the same claim.

NCCI edits and add-on rules

In the practitioner PTP file v323r0, G0475 is the column-2 (bundled) code in 1 active pair, 0% of which allow a modifier and the column-1 code in 10 (70% modifier-allowed); 0 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: Mutually exclusive procedures.

Column-1 codes most often paired with G0475 (practitioner)
Column-1 codePairs
87806 (CPT; descriptor licensed by AMA)1
Column-2 codes bundled into G0475 (practitioner)
Column-2 codePairs
86701 (CPT; descriptor licensed by AMA)1
86702 (CPT; descriptor licensed by AMA)1
86703 (CPT; descriptor licensed by AMA)1
87389 (CPT; descriptor licensed by AMA)1
87390 (CPT; descriptor licensed by AMA)1
87534 (CPT; descriptor licensed by AMA)1
87535 (CPT; descriptor licensed by AMA)1
87536 (CPT; descriptor licensed by AMA)1

In the hospital outpatient PTP file v323r0, G0475 is the column-2 (bundled) code in 1 active pair, 0% of which allow a modifier and the column-1 code in 10 (70% modifier-allowed); 0 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: Mutually exclusive procedures.

Column-1 codes most often paired with G0475 (hospital outpatient)
Column-1 codePairs
87806 (CPT; descriptor licensed by AMA)1
Column-2 codes bundled into G0475 (hospital outpatient)
Column-2 codePairs
86701 (CPT; descriptor licensed by AMA)1
86702 (CPT; descriptor licensed by AMA)1
86703 (CPT; descriptor licensed by AMA)1
87389 (CPT; descriptor licensed by AMA)1
87390 (CPT; descriptor licensed by AMA)1
87534 (CPT; descriptor licensed by AMA)1
87535 (CPT; descriptor licensed by AMA)1
87536 (CPT; descriptor licensed by AMA)1

G0475 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.

Pair counts show exposure, not the answer for one claim. Check G0475 against a second code to see whether the pair bundles and whether a modifier can separate the services.

Medicare coverage policies for G0475

No current LCD or billing and coding article lists G0475. The HCPCS coverage code C means carrier judgment, so the Medicare contractor decides coverage, and any National Coverage Determination for the service still applies.

Denials to expect on G0475

CARC 50 · N115

the service is not reasonable and necessary for the diagnosis on the claim

CARC 151 · N362

units of G0475 exceed the practitioner MUE of 1 per date of service

CARC 4

the modifier reported is inconsistent with the code

CARC 16

the claim lacks the description, invoice or pricing detail a contractor-priced code needs

Where QuickIntell fits for G0475 claims

QuickCode supports qualified coder review of units, modifiers and NCCI pairs for G0475 before the claim leaves, and QuickRCM carries claim readiness and the denial follow-up when an edit or coverage policy is missed.

See QuickCode for coder reviewSee QuickRCM for denial follow-upBook a meeting

Frequently asked questions: HCPCS G0475

What does HCPCS code G0475 describe?

"Hiv antigen/antibody, combination assay, screening" (short descriptor "Hiv combination assay"), in the G section (procedures and professional services, temporary). Added 2015-04-13.

Is G0475 a CPT code?

It is not. G0475 belongs to the G section (procedures and professional services, temporary) of HCPCS Level II, the CMS code set, not to AMA CPT.

What does Medicare pay for G0475?

The 2026 Q4 clinical laboratory fee schedule pays G0475 $24.08 (national limitation amount), also listed with QW.

How many units of G0475 can be billed per day?

CMS caps G0475 at practitioner 1 (MAI 2, CMS Policy); hospital outpatient 1 (MAI 2, CMS Policy) units per day in the 2026 Q4 MUE tables. For the practitioner MUE (MAI 2), units above 1 deny for the whole day as a policy limit; denials arrive as CARC 151.

Does Medicare cover G0475?

G0475 appears in no active LCD or billing and coding article, so coverage follows HCPCS coverage code C (carrier judgment, so the Medicare contractor decides coverage) and any NCD.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

Disclaimer

This page is an operational reference compiled from CMS publications: the HCPCS Level II file, the physician, DMEPOS and clinical laboratory fee schedules, OPPS and ASC addenda, NCCI MUE, PTP and add-on edit tables and the Medicare Coverage Database. Amounts are Medicare national figures before locality and state adjustment; Medicaid and commercial payers set their own. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.