Medicare Part B Preventive Services: Quick Reference Chart January 2009

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1 Initial Preventive Physical Examination (IPPE) Also known as the Welcome To Medicare Visit (WMV) Medicare Part B Preventive Services: Quick Reference Chart Effective January 1, 2009 No specific diagnosis Once in a lifetime benefit code required for IPPE per beneficiary. Cardiovascular Disease G0402 IPPE G0403 EKG for IPPE G0404 EKG Tracing for IPPE G0405 EKG Interpret & Report Lipid Panel Cholesterol Lipoprotein Triglycerides Important: Effective for dates of service on or after January 1, 2009, the screening EKG is an optional service that may be performed as a result of a referral from an IPPE Report one or more of the following : V81.0, V81.1, V81.2 *All Medicare beneficiaries whose Part B coverage begins on or after January 1, 2005 *All asymptomatic Medicare beneficiaries 12 hour fast is required prior to testing Must be furnished no later than 12 months after the beneficiary s effective date of Medicare Part B coverage Every 5 years -Deductible applies prior to 1/4/09 - applies for code G0402, effective for dates of service on or after 1/1/09 -Deductible still applies for G0403, G0404 and G0405 MM6223 Section 80 MM 3411 Section 100 Diabetes Test Requires physician or non-physician referral Glucose, quantitative, blood (except reagent strip) Post-glucose dose (includes glucose) Tolerance test (GTT), three specimens (includes glucose) V77.1 Report modifier TS (follow up service) for diabetes screening where the beneficiary meets the definition of pre-diabetes *Medicare beneficiaries with certain risk factors for diabetes or diagnosed with pre-diabetes Beneficiaries previously diagnosed with diabetes are not eligible for this benefit - 1 screening test every six months for beneficiaries diagnosed with pre-diabetes - 1 screening per year if previously tested but not diagnosed with prediabetes, or if never tested MM3677 Section 90 Abdominal Aortic Aneurysm (AAA) G0389 Ultrasound, B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening No specific diagnosis code required for AAA All Medicare beneficiaries who receives a referral for such an ultrasound screening as a result of an IPPE Medicare beneficiaries entitled to a one-time AAA ultrasound screening MM5235 Section 110 Bone Mass Measurement 76977, 77078, 77079, 77080, 77081, 77083, G , 246.9, , 256.2, , , 259.3, 627.2, 627.4, , , , , , , V49.81, V58.65 Medicare beneficiaries at risk for developing Osteoporosis Every 24 months (more frequently if medically necessary) *Effective for services furnished on or after January 1, 2005, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides for coverage of the IPPE, cardiovascular disease and diabetes screening tests under Part B, subject to certain eligibility and other limitations. Page 1 of 4 MM5521 Chapter 13, Section 140

2 Medicare Part B Preventive Services: Quick Reference Chart G0108 DSMT, individual session, per 30 minutes Diabetes Self- Management Training (DSMT) Physician must certify that DSMT is needed Medical Nutrition Therapy (MNT) Requires physician referral G0109 DSMT, group session (2 or more), per 30 minutes 97802, 97803, 97804, G0270, G0271 Services must be provided by dietitian or nutritionist All individuals who are at risk for complications from diabetes for whom it has been physician ordered V42.0, , 585, 586, 593.9, 646.2, Medicare beneficiaries at risk for complications from diabetes or recently diagnosed with diabetes or previously diagnosed with diabetes Physician must certify that DSMT is needed Medicare beneficiaries diagnosed with diabetes or a renal disease A plan of care must be written to include: number of sessions, frequency and duration Up to 10 hours of initial training within a continuous 12-month period Subsequent years: Up to 2 hours of follow-up training each year - 1st year 3 hours of oneon-one counseling - Subsequent years 2 hours PUB 100-2, Chapter 15, Section 300 PUB 100-3, Chapter 1, Section 180 Pap Test G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091 V15.89, V72.31, V76.2, V76.47, V76.49 All female Medicare beneficiaries - if high-risk or childbearing age with abnormal Pap test within past 3 years - Every 24 months for all other women for Pap test collection. (No copayment for Pap lab test) Section 30 Pelvic Exam G0101- Cervical or vaginal cancer screening; pelvic and clinical breast examination V15.89, V72.31, V76.2, V76.47, V76.49 All female Medicare beneficiaries - if high-risk or childbearing age with abnormal Pap test within past 3 years - Every 24 months for all asymptomatic women Section 40 This quick reference chart was prepared as an information reference source by Highmark Medicare Services for health care professionals in Pennsylvania. This chart is intended to complement and not replace Medicare program requirements as set forth in statute, regulations and manual instructions. It is the responsibility of each health care professional/supplier submitting claims to Highmark Medicare Services to familiarize themselves with Medicare coverage requirements. Highmark Medicare Services makes efforts to ensure the information contained in this quick reference chart is accurate and current. Page 2 of 4

3 Medicare Part B Preventive Services: Quick Reference Chart 77052, 77057, G0202 V76.11 or V76.12 All female Medicare Mammography beneficiaries age 40 or older Female Medicare One baseline beneficiaries ages Section 20 Glaucoma Influenza (Flu) Virus Vaccine Pneumococcal Vaccine G0117 By an optometrist or ophthalmologist G0118 Under the direct supervision of an optometrist or ophthalmologist 90655, 90656, 90657, & Influenza Virus Vaccine G0008 Administration Pneumococcal Conjugate Vaccine Pneumococcal polysaccharide Vaccine (PPV) V80.1 Medicare beneficiaries with diabetes mellitus, family history of glaucoma, African- American age 50 & over or Hispanic-American age 65 & over V04.81 V When purpose of visit was to receive both Flu & PPV vaccines V03.82 V When purpose of visit was to receive both PPV & Flu vaccines All Medicare beneficiaries All Medicare beneficiaries for beneficiaries in one of the high risk groups. Once per flu season in the fall or winter More frequently if medically necessary Once in a lifetime Medicare may provide additional vaccinations based on risk Section 70 Section 10 Section 10 G0009 Administration Hepatitis B (HBV) 90740, 90743, 90744, 90746, HBV G0010 Administration V05.3 Medicare beneficiaries at medium to high risk Scheduled dosages required Section 10 Smoking and Tobacco-Use Cessation Counseling Counseling visit; intermediate, greater than 3 minutes up to 10 minutes counseling visit; intensive, greater than 10 minutes Report the appropriate diagnosis code for the condition the patient has that is adversely affected by the use of tobacco Medicare beneficiaries who use tobacco and have a disease or adverse health effect linked to tobacco use or take certain therapeutic agents whose metabolism or dosage is affected by tobacco use 2 cessation attempts per year; each attempt includes maximum pf 4 intermediate or intensive sessions, up to 8 sessions in a 12-month period PUB 100-3, Chapter 1, Section *Effective for services furnished on or after January 1, 2005, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides for coverage of the IPPE, cardiovascular disease and diabetes screening tests under Part B, subject to certain eligibility and other limitations. Page 3 of 4

4 Medicare Part B Preventive Services: Quick Reference Chart Prostate Cancer G0102 Digital Rectal V76.44 All male Medicare Exam (DRE) beneficiaries 50 or older Colorectal Cancer G0103 Prostate Specific Antigen Test (PSA) G0104-Flexible Sigmoidoscopy G0105- Colonoscopy (high risk) G0106-Barium Enema (alternative to G0104) Fecal-Occult Blood Test G0120-Barium Enema (alternative to G0105) G0121-Colonoscopy (not high risk) G0328-Fecal-Occult Blood Test (alternative to 82270) V76.44 All male Medicare beneficiaries 50 or older , 555.9, , 556.8, 556.9, 558.2, 558.9, V10.05, V10.06, V12.72, V16.0, V18.51, V18.59, V , 555.9, , 556.8, 556.9, 558.2, 558.9, V10.05, V10.06, V12.72, V16.0, V18.51, V18.59, V76.51 Medicare Beneficiaries age 50 and older Patients who are at high risk for colorectal cancer Medicare beneficiaries age 50 and older who are not at high risk for colorectal cancer Medicare Beneficiaries age 50 and older Patients who are at high risk for colorectal cancer Individuals not at high risk for developing colorectal cancer Medicare beneficiaries age 50 and older Every 4 years or once every 10 years after having a screening colonoscopy Every 24 months Every 4 years not at high risk Every 24 months at high risk and at least 23 months since last screening BE or screening colonoscopy Once every 10 years and not within 48 months of screening sigmoidoscopy Effective January 1, 2007, no for colorectal cancer screening tests. or for Fecal-Occult Blood Tests Effective January 1, 2007 no for colorectal cancer screening tests or for Fecal-Occult Blood Tests Section 50 Section 50 Section 60 This quick reference chart was prepared as an information reference source by Highmark Medicare Services for health care professionals in Pennsylvania. This chart is intended to complement and not replace Medicare program requirements as set forth in statute, regulations and manual instructions. It is the responsibility of each health care professional/supplier submitting claims to Highmark Medicare Services to familiarize themselves with Medicare coverage requirements. Highmark Medicare Services makes efforts to ensure the information contained in this quick reference chart is accurate and current. Page 4 of 4

5 Highmark Medicare Services Part B Provider IVR Quick Reference Information is just a Telephone Call Away PA, NJ, MD, DCMA and DE Providers dial The Interactive Voice Response Unit is easy to use. All you need is: The State in which the services were rendered. Your NPI and PTAN numbers Your patient s name & Medicare number (nine numbers followed by a letter) and the date of service in question for claim status. If you key the name, only enter the first six letters of the last name followed by the first initial. The month, day and year of birth of a patient to obtain eligibility Telephone with handset or headset. The use of speakerphones and cell phones are not recommended. A quiet environment that you can speak clearly and naturally into your telephone. You must be registered to use the fax option, faxes will only be sent to your registered fax numbers. Main Menu Say the option name or press the corresponding numeric (1) Eligibility (2) Claim Status (3) Checks and Earnings to Date (4) Pricing (5) Frequently requested Telephone Numbers Telephone Appeals Provider Enrollment EDI Railroad Medicare Beneficiary Services (6) Frequently requested Addresses General Inquiries Provider Enrollment Claim Submissions Highmark Website Freedom of Information (7) Medicare News (8) Appeal Rights (9) Fax On Demand Claim Status Information You will receive the following claim status information Claim Level Details Number of claims for the DOS Pending, processed, denied or rejected Amount Submitted Allowed Amount Amount applied to the Amount Paid Paid Date Check Number Date of development if applicable and to whom Line Level Details Claim Control Number Number of line items DOS Amount submitted Allowed amount Procedure Code and modifier Diagnosis code Reason for denial if one of the top 100 Eligibility You will receive the following information Part A and B effective dates Date of Death Part B current and prior PT/OT amounts Medicare Primary or Secondary based on the dates and reason Medicare Advantage and Home Health Information Check Information You will receive the following check information Check Number Check Issue Date Check Amount Cash date Check Status if not cashed outstanding, cancelled or voided Using the touchtone keypad to Enter HIC Number s In order to enter a patients HIC number using touch tone, you must use the numbers on the telephone keypad that correspond to the numbers in the HIC. To key the alpha suffix, press the * key to signal that you are entering a letter and press the key that includes the letter. Then press the corresponding number that denotes where the letter is located on the number key. For example, to enter A, you would key: * 21. The * indicates that the next entry is the letter, the letter A appears on the number 2 key in the first position. Other common letter entries: B = *22 D = *31 T = *81 W = *91 C = *23 M = *61 Q = *11 Z = *12 Helpful Hints: Once you are comfortable with the call flow, you can speak and key without listening to the entire prompt. Saying Main Menu will always bring you to the beginning of the call flow. Saying Operator will transfer your call to a CSR.

6 Say Eligibility or Press 1 Say or enter the Patient s Medicare Number. You can use the touch tone keypad for the HIC (Refer to the instructions on the front) Say or enter the Patient s name as it appears on their Medicare card. You can use the touch tone keypad for the name by selecting the key that corresponds to the first six letters of the patient s last name, followed by the first initial. Say or enter the patient s Date of Birth Say or enter the date of service in MMDDYYYY format so that MSP and HMO files can be verified. (No future dates) After you receive your information you can Say Repeat that Say Change Date to enter a different date of service for the same HIC Enter another HIC when you hear the prompt Another Medicare number Say Claim Status or Press 2 Say or enter the Patient s Medicare Number. You can use the touch tone keypad for the HIC (Refer to the instructions on the front) Say or enter the Patient s name as it appears on their Medicare card. You can use the touch tone keypad for the name by selecting the key that corresponds to the first six letters of the patient s last name, followed by the first inital. Say or enter the date of service in MMDDYYYY format. After you receive your information you can Say Repeat that or press 1 Say Next Claim or press 2 Say Previous Claim or press 3 Say Claim details or press 4 Say Additional Info (PTANs) or press 5 Say Change Date or press 6 Say Change Medicare number or press 7 Say Change PTAN or press 8 Say Change NPI or press 9 Say Pricing or Press 4 Say or enter the procedure code and modifier Say or enter the date of service Say or enter the zip code of your office Say or enter the locality of your office 01 or 99(PA/MD/NJ)* After you receive the pricing information you can Repeat the information or press 1 Say Change the procedure code or press 2 Say Change the PTAN or press 3 Say Change NPI or press 4 * Note: PA, NJ and MD Locality Information Please see our Highmark Medicare Services Website Self Service page, if you do not know your pricing locality. Say Checks and Earnings To Date or Press 3 Say Checks (press 1) or Say Earnings to date (press 2) Check number or press 1 Enter the 9 digit check number After you receive this information you can: Say Repeat the information or press 1 Say Change check number or press 2 Say Additional info (PTANs) or press 3 Say Change the PTAN or press 4 Say Change the NPI or press 5 Check Status or press 2 Say Outstanding or press 1 Say Paid or press 2 Stopped or press 3 Voided or press 4 Range of Dates or press 3 Say the starting date and ending dates in MMDDYYYY format After you receive the check information by status or range of dates you can: Say Repeat the information or press 1 Say Next check or press 2 Say Previous check or press 3 Say Change the date or press 4 Say Change the status or press 5 Say Additional info (PTANs) or press 6 Say Change the PTAN or press 7 Say Change the NPI or press 8 If you select Earnings To Date, you will hear your Current approved to pay amount Month-to-date earnings Year-to date earnings After you receive this information you can Say Repeat that or press 1 Say Change the PTAN or press 2 Say Fax On Demand or Press 9 Say Office or press 1 Say Billing or press 2 Say Other or press 3 Enter your registered other fax number After you enter this information, select from the following: Provider Summary or press 1 Pending Claims or press 2 Finalized Claims or press 3 You will be prompted to enter the beginning and ending date range. After you request your fax, you can Repeat the information or press 1 Say Another fax for the same PTAN or press 2 Say Change the PTAN number or press 3 Say Change NPI or press 4 Security: Press 1 to have your documents sent to the number we have on file for your home office. Press 2 to have your documents sent to the number we have on file for your billing office. Press 3 to enter another fax number you previously registered with us. Last Updated 12/16/2008

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