New HCPCS Code G0545 Complex Infectious Disease
As of January 1, 2025, this new HCPCS code has represented a cause for confusion providers wrestle with the appropriate applications for this service. HCPCS code G0545 is an add on code slated for use with inpatient or outpatient observation care (99221-99223 and 99231-99236). This code is not for use in the outpatient office setting. It was valued by the RUC committee/CMS at 0.89 total relative value units or $28.00.
HCPCS code G0545 acknowledges the unique challenges encountered by infectious disease specialists associated with infectious disease cases in hospital settings. The addition of this code acknowledges the unique, intricate decision-making and risk management, included in infection control. The collaboration with public health agencies, and personalized antimicrobial therapy management are considered above and beyond “normal” Evaluation and Management services. According to CMS, infectious diseases require extensive medical review because resistance patterns and public health risks continually evolve, posing unique challenges for patient management and community safety. CMS indicated the following key components are associated with furnishing this service.
Key Components of HCPCS Code G0545
HCPCS code G0545 allows infectious disease specialists to report additional complexity beyond standard Evaluation and Management (E/M) hospital codes. This add-on code covers three main areas:
1. Disease Transmission Risk Assessment and Mitigation – Includes specialized infection control measures, counseling for patients and caregivers, and care coordination to reduce transmission risks.
2. Public Health Investigation, Analysis, and Testing – Encompasses thorough patient history reviews, specialized diagnostic evaluations, and coordination with public health authorities for contact tracing and diagnostic testing.
3. Complex Antimicrobial Therapy Counseling and Treatment – Involves advising patients and families on antimicrobial stewardship, managing resistance concerns, and selecting appropriate therapies based on population health considerations.
The Infectious Disease Society of America (IDSA) cited the following in their FAQ sheet, please see the website for the full FAQ. (g0545-fact-sheet.pdf):
Question 5 - What documentation is required to bill G0545?
Answer: To ensure the additional complexity is justified for billing physicians must document:
• The infectious disease diagnosis or suspected condition.
• Specialized evaluations (e.g., review of resistance patterns or lab results).
• Management decisions reflecting the added complexity (e.g., changes in antimicrobial therapy, infection control strategies).
• Coordination with labs, public health agencies, or interdisciplinary teams.
Question 10 - How does CMS ensure appropriate use of G0545?
Answer: CMS requires that documentation clearly supports the infectious disease-specific complexity, including tasks such as coordinating with labs or public health agencies, managing antimicrobial resistance, or developing complex care plans. Claims may be subject to audit to ensure compliance.
Coders, compliance professionals and billers will want to have a system of checks and balances in place to avoid external third party audit and fines. This $28.00 charge is not worth a False Claim finding and the associated civil monetary penalties.
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