Should Your Urgent Care Center Offer HIV Testing?

Urgent Message: To enable early detection and treatment to help curb future transmissions, CDC guidelines recommend HIV testing be available for patients in all healthcare settings, including urgent care centers. HIV testing can be a practical, profitable, public health service for urgent care centers.

Many patients, especially millennials, rely on urgent care as their “provider of first choice.” These are patients who are generally healthy and have no chronic conditions requiring long-term management, but who do need someplace to go when the occasional illness or injury strikes. In addition, these patients tend to seek urgent care when concerned about sexually transmitted diseases. Urgent care offers neighborhood, walk-in convenience without the “stigma” or “embarrassment” that deters some patients from specialized providers like Planned Parenthood or the public health department. Given a base of patients concerned about sexually transmitted diseases, testing for the human immunodeficiency virus (HIV) can be a practical, profitable, public health service offered by urgent care centers.

Public Health Justification for HIV Testing

According to government data, the United States has approximately 1.2 million people living with HIV. Up to 250,000 people (25%) are unaware of their infections. People who are unaware they are HIV+ may be responsible for up to half of new sexual transmissions of HIV. Every 9 minutes another person becomes infected with HIV, totaling nearly 56,000 new infections every year, a number that has remained largely unchanged for the last 15 years.^1,2 In a large study of HIV-infected persons, 65% reported they were first tested for HIV only after they developed symptoms of illness.

Life-saving treatment that can suppress the virus and prevent progression to acquired immunodeficiency syndrome (AIDS) is available. However, the benefits are most effective for those who are diagnosed early, where modern antiretroviral therapy can convey a high quality of life and near-normal survival for a condition that was once a death sentence. Pregnant women who are infected with HIV should also be identified, as treatment can prevent transmission to their babies. Modern preemptive therapies are also available for those who are at risk of HIV infection, which can reduce the rate of HIV infection by up to 96%.³

Delayed HIV screening and testing results in delayed diagnosis, leading to preventable and devastating complications. Forty percent of people develop AIDS within a year of being diagnosed with HIV—indicating that these are late diagnoses. Late diagnosis contributes to increased healthcare costs and transmission of HIV to more people, poor medical outcomes, decreased productivity, and early death. Whilst HIV is not the same ravaging epidemic today as it was 20 years ago, more than 14,000 people still die every year of AIDS in the United States.³
In response, policy makers initiated new screening guidelines in 2006. The CDC recommends all people between 13 and 64 years of age be tested as part of routine medical care irrespective of risk profile, with more frequent testing for those at increased risk of HIV infection.^4-6

Peer-reviewed evidence-based guidelines have been developed, aimed at reaching the goal of having 74% of the population screened by 2020. These guidelines cover risk stratification, screening, counseling and follow-up care. Population-level reporting is also recommended at a state and federal level. Table 1 summarizes the CDC HIV screening guidelines.

Table 1. CDC HIV Screening Guidelines¹

Consent, Confidentiality and Pretest Counseling

There is no requirement to obtain specific written consent for HIV testing; oral consent can be documented if written consent for medical care has been given. Best-practice guidelines suggest patients should be informed testing will occur, and given the opportunity to decline, or opt out from testing. Pretest counseling is not required. HIV test results are covered under standard HIPAA confidentiality standards. Confidentiality obligations do not prevent providers from reporting HIV infection to public health agencies.^1,6 Despite concerns over the lack of HIV prevention counseling in conjunction with HIV testing, the CDC recognizes such can become a barrier to testing in busy healthcare settings.

Risk Stratification

Patients should be assessed for risk factors indicating high risk for screening. Individuals at high risk should be offered testing on an annual basis. Individuals at normal risk should be screened at least once in their life. Table 2 summarizes risk factors for HIV infection. Screening is recommended in all healthcare settings, including emergency rooms, primary care practices, and urgent care centers. Screening in patients who are younger than 15 or older than 65 should be assessed on an individual basis, concordant with the presence or absence of risk factors.^1,6 Generally, because urgent care is episodic and focused on treating the patient’s presenting condition, unless the patient’s medical compliant is related to an HIV risk factor, it’s probably more common that urgent care patients will request HIV testing as opposed to the urgent care provider recommending it.

Table 2. Factors Constituting High Risk for HIV Infection

Post Test Counseling

Negative HIV test results are treated as any other negative lab result unless the patient requests further testing due to ongoing risks. Healthcare providers are obligated to provide, or arrange for, appropriate posttest counseling in the event of a positive HIV result. Counseling includes:

• Delivering HIV screening test results
• Evaluating and supporting patient understanding and insight
• Notifying possible partners of positive screening results
• Clinical review, including assessment, examination, and referral
• Preventive counseling to patients and providers

While it may not be practical to provide counseling services in the urgent care center, arrangements can be made for patients with positive test results to receive counseling through the public health department or other community resources. Public health disease intervention specialists are available to provide results, linkage to care, and other services for all newly reported HIV+ cases. Before implementing an HIV testing program, the urgent care should have a plan for dealing with positive test results.

Public Health Reporting

There are state-by-state guidelines that mandate reporting of positive HIV screens as part of local and national surveillance programs.^1,8 Prompt and accurate reporting supports the ability to public health bodies to monitor and provide interventions in high-risk areas. In most instances, positive results will be reported by the reference lab conducting the test. In the case of point-of-care or instant tests performed in the center, it’s important to check with your local health department to confirm reporting requirements. Local and regional health authorities follow up on all newly reported HIV+ cases to ensure linkage to treatment, prevention counseling, and partner services. Medication funding and other support programs are available for eligible persons who test positive.

HIV Screening Tests

As Table 3 illustrates, there are two HIV tests commonly performed in the urgent care center. One is a collection and send-out and the other is an instant, point-of-care test. Positive results from the instant test should be verified by conventional immunoassay testing.

Table 3. Types of HIV Tests Performed in Urgent Care Centers⁴

Billing and Coding

Health Care Common Procedural codes are reimbursable for rapid point-of-care testing and standard immunoassay testing, as well as newer combination testing. Screening “Z” ICD-10-CM codes should be used for screening encounters, and disease-specific codes should be used in known cases of HIV, or high-risk management of pregnancy. Table 4 provides common codes for HIV testing and diagnosis.

Because many urgent care payer contracts are “case rate,” which reimburses a flat fee for Evaluation and Management services and includes all diagnostic testing related to the visit, it’s not possible under many urgent care contracts to get reimbursed separately by insurance for an HIV test. Thus, many urgent care centers consider HIV testing to be a “cash” service, paid by the patient out-of-pocket. Urgent care center pricing for self-pay rapid HIV testing ranges from as low as $55 to as high as $200. Some urgent care centers bundle HIV with a complete panel of STD tests, which can be priced as high as $350.

Table 4. Codes for Billing and Diagnosis for HIV

Alan A. Ayers, MBA, MAcc is Vice President of Strategic Initiatives for Practice Velocity, LLC and is Practice Management Editor for The Journal of Urgent Care Medicine.
References

1. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55:1–17.
2. Centers for Disease Control and Prevention. HIV Case Reporting and Surveillance. Available at: https://www.cdc.gov/hiv/guidelines/reporting.html. Accessed March 27, 2017.
3. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med. 2000;342(13):921-929.
4. Centers for Disease Control and Prevention and Association of Public Health Laboratories. Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations. Available at http://stacks.cdc.gov/view/cdc/23447. June 27, 2014. Accessed March 27, 2017.
5. Bolduc P, Roder N, Colgate E, Cheeseman SH. Care of Patients with HIV infection: diagnosis and monitoring. FP Essent. 2016;443:11-15.
6. Hall HI, An Q, Tang T, et al. Prevalence of Diagnosed and Undiagnosed HIV Infection–United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2015;64(24):657-662.
7. Moyer VA. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(1):51-60.
8. Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. HIV Infection: Detection, Counseling, and Referral. Atlanta, GA: CDC, 2015. Available at https://www.cdc.gov/std/tg2015/hiv.htm#a3. Accessed March 27, 2017.

Alan A. Ayers, MBA, MAcc

President of Experity Consulting and is Practice Management Editor of The Journal of Urgent Care Medicine