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1 /0$#0&$1!"#$%&'##()(*$+,-$.#%.$/+,-$%0#,'1$&23#'#4$56$7#4)&,'#$)%$,$8,52',.2'6$.#%.$.",.$&2(%)%.%$29$,$'2:.)(#$ #;928),.)3#$&6.282*6$.#%.$/+,-,()&28,2:$.#%.1$-'23)4#4$92'$."#$-:'-2%#$29$#,'86$4#.#&.)2($29$&#'3)&,8$&,(&#'<$ =.$)(&8:4#%$&288#&.)2($29$,$%,0-8#$29$&#'3)&,8$&#88%$,(4$,$-"6%)&),(>%$)(.#'-'#.,.)2($29$."#$.#%.< A cervical screening detects significant abnormal cell changes that may arise before cancer develops;."#'#92'#?$)9$4),*(2%#4$,(4$.'#,.#4$#,'86?$,(6$,5(2'0,8$&#88$&",(*#%$.",.$0,6$2&&:'$23#'$.)0#$&,($5#$ reduced or prevented. The cervical screening benefit covered by Medicare can aid in reducing illness and 4#,."$,%%2&),.#4$@)."$,5(2'0,8$&#88$&",(*#%$.",.$0,6$8#,4$.2$&#'3)&,8$&,(&#'< 7#4)&,'#>%$&23#',*#$29$."#$%&'##()(*$+,-$.#%.$@,%$&'#,.#4$,%$,$'#%:8.$29$."#$)0-8#0#(.,.)2($29$."#$A0()5:%$ B:4*#.$C#&2(&)8),.)2($D&.$29$EFGF$/ABCD$EFGF1<$!")%$D&.$,:."2')H#4$7#4)&,'#$.2$5#*)($&23#')(*$%&'##()(*$ Pap tests provided to female beneficiaries on or after July 1, 1990.!"#$$%&%'()*+(,$-.- 2&-3(4*".5#- I)*"$')%J$9,&.2'%$92'$&#'3)&,8$,(4$3,*)(,8$&,(&#'$)(&8:4#$."#$92882@)(*K L,'86$2(%#.$29$%#;:,8$,&.)3).6$/:(4#'$EM$6#,'%$29$,*#1? 7:8.)-8#$%#;:,8$-,'.(#'%$/N$2'$02'#$)($,$8)9#.)0#1? I)%.2'6$29$,$%#;:,886$.',(%0)..#4$4)%#,%#$O)(&8:4)(*$":0,($-,-)8820,3)':%$/I+P1$,(4Q2'$I:0,($ Immunodeficiency Virus (HIV) infection], R#@#'$.",($S$(#*,.)3#$+,-$.#%.%$2'$(2$+,-$.#%.$@).")($."#$-'#3)2:%$T$6#,'%?$,(4 ULV$/4)#."68%.)85#%.'281W#;-2%#4$4,:*".#'%$29$@20#($@"2$.22J$ULV$4:')(*$-'#*(,(&6< 650$#*'$(7%85#9*.&5% Medicare provides coverage of a screening Pap test for all female beneficiaries. A doctor of medicine or osteopathy or other authorized practitioner (i.e., a certified nurse midwife, physician assistant, nurse -',&.).)2(#'?$2'$&8)()&,8$(:'%#$%-#&),8)%.1?$@"2$)%$,:."2')H#4$:(4#'$V.,.#$8,@$.2$-#'92'0$."#$#;,0)(,.)2($ 0:%.$2'4#'$,(4$&288#&.$."#$%&'##()(*$+,-$.#%.<$R'#X:#(&6$29$&23#',*#$)%$-'23)4#4$,%$92882@%K Y23#'#4$2(&#$#3#'6$EZ$02(."%K 7#4)&,'#$-'23)4#%$&23#',*#$29$,$%&'##()(*$+,-$.#%.$,((:,886$/)<#<?$,.$8#,%.$EE$02(."%$",3#$-,%%#4$92882@)(*$ the month in which the last Medicare-covered Pap test was performed) for female beneficiaries who meet 5%$$29$."#$92882@)(*$&').#'),K There is evidence (on the basis of her medical history or other findings) that the woman is of &")845#,')(*$,*#$,(4$",%$",4$,($#;,0)(,.)2($.",.$)(4)&,.#4$."#$-'#%#(&#$29$&#'3)&,8$2'$3,*)(,8$ &,(&#'$2'$2."#'$,5(2'0,8).)#%$4:')(*$,(6$29$."#$-'#&#4)(*$S$6#,'%?$2' There is evidence that the woman is in one of the high risk categories (previously identified) for developing cervical or vaginal cancer, or has other specified personal history presenting hazards.2$"#,8."< :;<

2 Y23#'#4$2(&#$#3#'6$Z[$02(."%K 7#4)&,'#$-'23)4#%$&23#',*#$29$,$%&'##()(*$+,-$.#%.$92'$,88$,%60-.20,.)&$(2(W")*"$')%J$9#0,8#$ beneficiaries every 2 years (i.e., at least 23 months have passed following the month in which the last &23#'#4$%&'##()(*$+,-$.#%.$@,%$-#'92'0#41< =/,>?(,@$(.$#9(A159*%(58("@&BCD$*#&%'(*'$E(9$*%-(*(159*%(1@5(&-(+#$9$%5+*F-*BG(*%C(@*-(D$$%( determined by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or other findings. Medicare provides coverage for a Pap test as a Medicare Part B benefit. The coinsurance or copayment applies for the Pap test collection; however, there is no Medicare Part B deductible for Pap test collection. The beneficiary will pay nothing for the Pap laboratory test (there is no deductible and no coinsurance or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preservative fluid, automated thin layer preparation, screening by cytotechnologist :(4#'$-"6%)&),($%:-#'3)%)2( V&'##()(*$&6.2-,."282*6?$&#'3)&,8$2'$3,*)(,8$/,(6$'#-2'.)(*$%6%.#01?$&288#&.#4$)($ preservative fluid, automated thin layer preparation, with manual screening and '#%&'##()(*$56$&6.2.#&"(282*)%.$:(4#'$-"6%)&),($%:-#'3)%)2( V&'##()(*$&6.2-,."282*6?$&#'3)&,8$2'$3,*)(,8$/,(6$'#-2'.)(*$%6%.#01?$&288#&.#4$)($ preservative fluid, automated thin layer preparation, with screening by automated %6%.#0$:(4#'$-"6%)&),($%:-#'3)%)2( V&'##()(*$&6.2-,."282*6?$&#'3)&,8$2'$3,*)(,8$/,(6$'#-2'.)(*$%6%.#01?$&288#&.#4$)($ preservative fluid, automated thin layer preparation, with screening by automated %6%.#0$,(4$0,(:,8$'#%&'##()(*$:(4#'$-"6%)&),($%:-#'3)%)2( V&'##()(*$&6.2-,."282*6$%0#,'%?$&#'3)&,8$2'$3,*)(,8?$-#'92'0#4$56$,:.20,.#4$ %6%.#0$:(4#'$-"6%)&),($%:-#'3)%)2( V&'##()(*$&6.2-,."282*6$%0#,'%?$&#'3)&,8$2'$3,*)(,8?$-#'92'0#4$56$,:.20,.#4$ %6%.#0$@)."$0,(:,8$'#%&'##()(* V&'##()(*$+,-,()&28,2:$%0#,'?$&#'3)&,8$2'$3,*)(,8?$:-$.2$."'##$%0#,'%?$56$.#&"()&),($:(4#'$-"6%)&),($%:-#'3)%)2(!"#$ 1+-##0'0%$.,.$!#1!1

3 )(.#'-'#.,.)2($29$%&'##()(*$+,-$.#%.%<$Y24#$%#8#&.)2($4#-#(4%$2($."#$'#,%2($92'$-#'92'0)(*$."#$.#%.?$."#$ 0#."24%$29$%-#&)0#($-'#-,',.)2($,(4$#3,8:,.)2(?$,(4$."#$'#-2'.)(*$%6%.#0$:%#4<$ (65C$ G0124 G0141 P3001 V&'##()(*$&6.2-,."282*6?$&#'3)&,8$2'$3,*)(,8$/,(6$'#-2'.)(*$%6%.#01?$&288#&.#4$)($ preservative fluid, automated thin layer preparation, requiring interpretation$ 56$-"6%)&),( V&'##()(*$&6.2-,."282*6$%0#,'%?$&#'3)&,8$2'$3,*)(,8?$-#'92'0#4$56$,:.20,.#4$ V&'##()(*$+,-,()&28,2:$%0#,'?$&#'3)&,8$2'$3,*)(,8?$:-$.2$."'##$%0#,'%?$'#X:)')(*$ )(.#'-'#.,.)2($56$-"6%)&),( 25.,)(%?$-'#-,'#%?$&2(3#6%$."#$.#%.?$,(4$%#(4%$."#$%-#&)0#($.2$,$8,52',.2'6< J6)6!(65C$ Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of &#'3)&,8$2'$3,*)(,8$%0#,'$.2$8,52',.2'6 When a Medicare provider files a claim for a screening Pap test, one of the screening ( V ) diagnosis codes listed in Tables 4 and 5 must be used. Code selection depends on whether the beneficiary is classified as 82@$')%J$2'$")*"$')%J<$!"#$-'23)4#'$0:%.$'#-2'.$.")%$4),*(2%)%$&24#?$,82(*$@)."$2."#'$,--8)&,58#$4),*(2%)%$ &24#%<$R,)8:'#$.2$'#-2'.$."#$PTZ<SE?$PTM<Z?$PTM<[T?$PTM<[F?$2'$PEN<GF$4),*(2%)%$&24#$@)88$'#%:8.$)($4#(),8$29$."#$&8,)0<,*DB$(K(I(J6)6!(65C$-(85#()@L-&"&*%M-(7%.$#+#$.*.&5%(58(!"#$$%&%'()*+(,$-.-,*DB$(<(I(J6)6!(65C$(85#(N*D5#*.5#L(!+$"&9$%(58()*+(,$-.- H&*'%5-&-(2$OF&#$9$%.-,*DB$(P(I(H&*'%5-&-(65C$-(85#(N51(2&-3(!"#$$%&%'()*+(,$-.- N51Q2&-3 76HQRQ6S( H&*'%5-&-(65C$ PTZ<SE PTM<Z PTM<[T C2:.)(#$\6(#&282*)&,8$L;,0)(,.)2($ =/,>?$!")%$4),*(2%)%$%"2:84$2(86$5#$:%#4$@"#($."#$-'23)4#'$-#'92'0%$,$ 9:88$*6(#&282*)&,8$#;,0)(,.)2(< V-#&),8$%&'##()(*$92'$0,8)*(,(.$(#2-8,%0%?$&#'3); V-#&),8$%&'##()(*$92'$0,8)*(,(.$(#2-8,%0%?$3,*)(, 1+-##0'0%$.,.$!#1!1$!"$

4 N51Q2&-3 76HQRQ6S( H&*'%5-&-(65C$ PTM<[F V-#&),8$%&'##()(*$92'$0,8)*(,(.$(#2-8,%0%?$2."#'$%).#%$ 76HQRQ6S( H&*'%5-&-(65C$ PEN<GF U&BB&%'(2$OF&#$9$%.- XC9&%&-.#*.&0$(65%.#*".5#-(YXU(SX6-Z When physicians or qualified non-physician practitioners are submitting claims to carriers/ab MACs,."#6$0:%.$'#-2'.$."#$,--'2-'),.#$IY+YV$&24#$,(4$."#$&2''#%-2(4)(*$4),*(2%)%$&24#$)($."#$I=+DD$GST$ +'29#%%)2(,8$#8#&.'2()&$&8,)0$92'0,.< =/,>?( In those cases where a supplier qualifies for an exception to the ASCA requirement, Form CMS-1500 may be used to submit these claims on paper. Form CMS-1500 has been revised to accommodate the reporting of the National Provider Identifier (NPI). All providers must use Form CMS-1500 (08-05) when submitting paper claims. Additional information on Form CMS-1500 can be found,.$ U&BB&%'(*%C(65C&%'(2$OF&#$9$%.-(V@$%(!FD9&..&%'(6B*&9-(.5(4&-"*B(7%.$#9$C&*#&$-WXU( S$C&"*#$(XC9&%&-.#*.&0$(65%.#*".5#-(Y47-WXU(SX6-Z V&'##()(*$+,-$.#%.$%#'3)&#%$0,6$5#$5)88#4$.2$,($ R=QDB$7DY$56$."#$.#&"()&,8$&20-2(#(.$&,.#*2'6?$ which is defined as services rendered outside the scope 29$."#$-"6%)&),(>%$)(.#'-'#.,.)2($29$."#$'#%:8.%$29$,($ #;,0)(,.)2(?$2'$."#$-'29#%%)2(,8$&20-2(#(.$&,.#*2'6?$ which is defined as a physician s interpretation of the '#%:8.%$29$,($#;,0)(,.)2(< ]"#($%:50)..)(*$&8,)0%$.2$R=%QDB$7DY%?$."#$7#4)&,'#$ -'23)4#'$0:%.$'#-2'.$."#$,--'2-'),.#$IY+YV$&24#?$."#$,--'2-'),.#$'#3#(:#$&24#?$,(4$."#$&2''#%-2(4)(*$ 4),*(2%)%$&24#$)($."#$I=+DD$GST$=(%.).:.)2(,8$#8#&.'2()&$ &8,)0$92'0,.< Administrative Simplification Compliance X".(6B*&9-(2$OF&#$9$%.-!"#$ D40)()%.',.)3#$ V)0-8)9)&,.)2($ Y20-8),(&#$ D&.$/DVYD1$'#X:)'#%$.",.$&8,)0%$5#$%:50)..#4$.2$ #8#&.'2()&,886$:%)(*$."#$^EZ$GSTW+$/-'29#%%)2(,81$ 2'$GSTW=$/)(%.).:.)2(,81$92'0,.$,%$,--'2-'),.#?$:%)(*$."#$3#'%)2($,42-.#4$,%$,$(,.)2(,8$%.,(4,'4$:(4#'$."#$ I#,8."$ =(%:',(&#$ +2'.,5)8).6$,(4$ D&&2:(.,5)8).6$ D&.$ /I=+DD1<$ D44).)2(,8$ )(92'0,.)2($ 2($."#%#$ 92'0,.%$&,($5#$92:(4$,.$"..-KQQ@@@<&0%<""%<*23Q ElectronicBillingEDITrans/08_HealthCareClaims.,%-$2($."#$Y7V$@#5%).#<!"%$ 1+-##0'0%$.,.$!#1!1

5 =/,>?( In those cases where an institution qualifies for an exception to the ASCA requirement, Form CMS-1450 may be used to submit these claims on paper. As of May 23, 2007, all providers must use Form CMS-1450 (UB-04) when submitting paper claims. Additional information on Form CMS-1450 can be found at /!AB%1$,(4$,%%2&),.#4$'#3#(:#$&24#%$8)%.#4$)($!,58#$MK$,*DB$([(I(4*"&B&.L(,L+$-G(,L+$-(58(U&BB-G(*%C(2$0$%F$(65C$-(85#(!"#$$%&%'()*+(,$-.-( 4*"&B&.L(,L+$,L+$(58(U&BB 2$0$%F$(65C$ I2%-).,8$=(-,.)#(.$+,'.$B$)(&8:4)(*$Y').)&,8$ D&&#%%$I2%-).,8$/YDI1$ EZ^ 0311 I2%-).,8$A:.-,.)#(.$ ES^ 0311 I2%-).,8$_2(W-,.)#(.$`,52',.2'6$V-#&)0#(%$ )(&8:4)(*$YDI E[^ 030X VJ)88#4$_:'%)(*$R,&)8).6$/V_R1$=(-,.)#(.$ +,'.$B$ ZZ^ 0311 V_R$A:.-,.)#(.$ ZS^ 0311 YDI GN^ 0311 C:',8$I#,8."$Y8)()&$/CIY1 Federally Qualified Health Center (FQHC) =/,>?( Revenue code 0923 must be used for billing code Q0091 (Table 3). =/,>?( CAHs electing Method II report professional services under revenue codes 096X, 097X, or 098X )($,44).)2($.2$'#-2'.)(*$."#$.#&"()&,8$&20-2(#(.< 1+-##0'0%$.,.$!#1!1$!"&

6 Additional Billing Instructions for Rural Health Clinics (RHCs) and Federally Qualified CIY%$,(4$ RaIY%$ 0:%.$ 5)88)(*$ in an RHC or a FQHC. The technical component is defined,%$%#'3)&#%$'#(4#'#4$2:.%)4#$."#$%&2-#$29$."#$-"6%)&),(>%$ )(.#'-'#.,.)2($29$."#$'#%:8.%$29$,($#;,0)(,.)2(<,$"@%&"*B(659+5%$%.$92'$+'23)4#'WB,%#4$CIY%$,(4$RaIY%K 65C&%'(,&+ D$%&'##()(*$+,-$.#%.$,(4$,$%&'##()(*$-#83)&$ #;,0)(,.)2($&,($5#$-#'92'0#4$4:')(*$."#$ %,0#$#(&2:(.#'<$]"#($.")%$",--#(%?$52."$ -'2&#4:'#$&24#%$%"2:84$5#$%"2@($,%$%#-,',.#$ 8)(#$).#0%$2($."#$&8,)0<$+8#,%#$%##$D44).)2(,8$ B)88)(*$=(%.':&.)2(%$92'$CIY%$,(4$RaIY%< R2'$,$%&'##()(*$+,-$.#%.?$."#$5,%#$-'23)4#'$0:%.$5)88$."#$R=QDB$7DY$:(4#'$5)88$.6-#$ES^?$E[^?$ZZ^?$ZS^?$ 2'$GN^?$,%$,--'2-'),.#?$:%)(*$."#$5,%#$-'23)4#'>%$=U$(:05#'$92882@)(*$."#$5)88)(*$)(%.':&.)2(%$,--8)&,58#$.2$."#$5,%#$-'23)4#'<$U2$(2.$:%#$."#$CIYQRaIY$-'23)4#'$=U$(:05#'$%)(&#$."#%#$%#'3)&#%$,'#$(2.$&23#'#4$,%$CIYQRaIY$%#'3)&#%<,$"@%&"*B(659+5%$%.$92'$=(4#-#(4#(.$CIY%$,(4$RaIY%K R2'$,$%&'##()(*$+,-$.#%.?$."#$-'23)4#'$29$."#$%#'3)&#$0:%.$5)88$."#$&,'')#'QDB$7DY$:(4#'$."#)'$-',&.).)2(#'$ =U$(:05#'$92882@)(*$."#$)(%.':&.)2(%$92'$5)88)(*$."#$&,'')#'QDB$7DY<$U2$(2.$:%#$."#$CIYQRaIY$ -'23)4#'$=U$(:05#'$%)(&#$."#%#$%#'3)&#%$,'#$(2.$&23#'#4$,%$CIYQRaIY$%#'3)&#%< )#58$--&5%*B( 659+5%$%.$92'$+'23)4#'WB,%#4$CIY%$,(4$RaIY%?$=(4#-#(4#(.$CIY%?$,(4 R'##%.,(4)(*$RaIY%K When a screening Pap test is furnished within an RHC/FQHC by a physician or qualified non-physician, the screening Pap test is considered an RHC/FQHC service. RHCs/FQHCs will use revenue code 052X.2$'#-2'.$."#$'#8,.#4$3)%).<$!"#$-'23)4#'$/CIYQRaIY1$29$,$%&'##()(*$+,-$.#%.$0:%.$5)88$."#$R=QDB$7DY$ :(4#'$5)88$.6-#$TE^$2'$TS^$'#%-#&.)3#86< =/,>?( =(4#-#(4#(.$CIY%$,(4$R'##%.,(4)(*$RaIY%$,'#$9'##%.,(4)(*$-',&.)&#%$.",.$,'#$(2.$-,'.$29$,$ "2%-).,8?$VJ)88#4$_:'%)(*$R,&)8).6$/V_R1?$2'$I20#$I#,8."$D*#(&6$/IID1<$+'23)4#'W5,%#4$CIY%$,(4$RaIY%$,'#$)(.#*',8$,(4$%:52'4)(,.#$-,'.%$29$"2%-).,8%?$V_R%?$2'$IID%?$,(4$:(4#'$&2002($ 8)&#(%:'#?$*23#'(,(&#?$,(4$-'29#%%)2(,8$%:-#'3)%)2(< 2$&9DF#-$9$%.(7%85#9*.&5% ]$%$#*B(7%85#9*.&5% Medicare provides coverage for the screening Pap test as a Medicare Part B benefit. The Medicare Part B 4#4:&.)58#$92'$%&'##()(*$+,-$.#%.%$,(4$%#'3)&#%$-,)4$92'$:(4#'$."#$7#4)&,'#$+"6%)&),($R##$V&"#4:8#$42#%$(2.$,--86<$!"#$&2)(%:',(&#$,(4$4#4:&.)58#$42$(2.$,--86$92'$."#$8,52',.2'6$+,-$.#%.<!"'$ 1+-##0'0%$.,.$!#1!1

7 2$&9DF#-$9$%.(58(6B*&9-(DL(6*##&$#-WXU(S$C&"*#$(XC9&%&-.#*.&0$(65%.#*".5#-(YXU(SX6-Z 7#4)&,'#$5,%#%$'#)05:'%#0#(.$92'$%&'##()(*$+,-$.#%.$%#'3)&#%$ 2($."#$Y8)()&,8$`,52',.2'6$R##$V&"#4:8#$2'$."#$7#4)&,'#$ +"6%)&),($R##$V&"#4:8#$/7+RV1<!"#$7#4)&,'#$+,'.$B$4#4:&.)58#$,(4$."#$&2)(%:',(&#$2'$ &2-,60#(.$42$%5.$,--86$92'$%&'##()(*$+,-$.#%.$%#'3)&#%$ -,)4$:(4#'$."#$Y8)()&,8$`,52',.2'6$R##$V&"#4:8#$/!,58#$ 3); however, the coinsurance or copayment D44).)2(,8$ )(92'0,.)2($,52:.$."#$ 7+RV$ D44).)2(,8$)(92'0,.)2($,52:.$."#$Y8)()&,8$ `,52',.2'6$R##$V&"#4:8#$&,($5#$92:(4$,.$"..-KQQ D44).)2(,8$ )(92'0,.)2($,52:.$ A++V$ &,($ 5#$ 92:(4$,.$ =/,>?(!"#$%,0#$-"6%)&),($0,6$'#-2'.$,$&23#'#4$L3,8:,.)2($,(4$7,(,*#0#(.$/LQ71$3)%).$,(4$&24#$ Q0091 for the same date of service if the E/M visit is for a separately identifiable service. In this case, modifier -25 must be reported with the E/M service and the medical records must clearly 42&:0#(.$."#$LQ7$%#'3)&#$'#-2'.#4<$B2."$-'2&#4:'#$&24#%$,'#$.2$5#$%"2@($,%$%#-,',.#$8)(#$).#0%$ on the claim. These services can also be performed separately during separate office visits. 2$&9DF#-$9$%.(58(6B*&9-(DL(4&-"*B(7%.$#9$C&*#&$-WXU(S$C&"*#$(XC9&%&-.#*.&0$( 65%.#*".5#-(Y47-WXU(SX6-Z 7#4)&,'#$5,%#%$'#)05:'%#0#(.$92'$02%.$%&'##()(*$+,-$.#%.$%#'3)&#%$2($."#$Y8)()&,8$`,52',.2'6$R##$V&"#4:8#$ 2'$."#$7+RV<$!"#$7#4)&,'#$+,'.$B$4#4:&.)58#$,(4$."#$&2)(%:',(&#$2'$&2-,60#(.$42$%5.$,--86$92'$%&'##()(*$+,-$.#%.$ %#'3)&#%$-,)4$:(4#'$."#$Y8)()&,8$`,52',.2'6$R##$V&"#4:8#$/!,58#$E1$@"#($5)88#4$.2$."#$R=QDB$7DY$O@)."$."#$ exception of HCPCS code Q0091 (Table 3)].!"#$7#4)&,'#$+,'.$B$4#4:&.)58#$)%$,8%2$@,)3#4$92'$%&'##()(*$+,-$.#%.$%#'3)&#%$-,)4$:(4#'$."#$7+RV$/!,58#$ 2); however, the coinsurance or copayment C5$-$,--86$@"#($5)88#4$.2$."#$R=QDB$7DY< For HCPCS code Q0091, the Medicare Part B deductible is waived; however, coinsurance or copayment does apply when billed to the FI/AB MAC. Payment for HCPCS code Q0091 in a hospital outpatient department )%$5,%#4$2($."#$A:.-,.)#(.$+'2%-#&.)3#$+,60#(.$V6%.#0$/A++V1<$D$V_R$)%$-,)4$5,%#4$2($."#$7+RV<$D$YDI$ )%$-,)4$2($,$'#,%2(,58#$&2%.$5,%)%<$CIYQRaIY$-,60#(.$92'$.")%$&24#$)%$5,%#4$2($."#$,88W)(&8:%)3#$',.#$92'$."#$ -'29#%%)2(,8$&20-2(#(.< 2$*-5%-(85#(6B*&9(H$%&*B R2882@)(*$,'#$#;,0-8#%$29$%).:,.)2(%$@"#($7#4)&,'#$0,6$ 4#(6$&23#',*#$29$%&'##()(*$+,-$.#%.%K The beneficiary who is not at high risk has received a &23#'#4$%&'##()(*$+,-$.#%.$@).")($."#$-,%.$.@2$6#,'%< The beneficiary who is at high risk has received a &23#'#4$%&'##()(*$+,-$.#%.$4:')(*$."#$-,%.$6#,'< S$C&"*#$(65%.#*".5#( 65%.*".(7%85#9*.&5%!2$ 25.,)($ &,' ' )#'QD B$ 7 DY$,(4$ R= QD B$ 7DY$&2(.,&.$)(92'0,.)2(?$3)%).$"..-KQQ@@@< &0%<""%<*23Q7`_+'24:&.%QU2@(82,4%Q Y,88Y#(.#'!288_:0U)'#&.2'6<H)-$2($."# Y7V$@#5%).#< 1+-##0'0%$.,.$!#1!1$!"(

8 7#4)&,'#$-'23)4#'%$0,6$9)(4$%-#&)9)&$-,60#(.$4#&)%)2($ )(&8:4#$Y8,)0$D4b:%.0#(.$C#,%2($Y24#%$/YDCY%1$,(4$ 2' R=QDB$7DY< Written Advance Beneficiary Notice of Noncoverage (ABN) Requirements Please refer to the Advance Beneficiary Notice of Noncoverage (ABN) Reference Section G of this publication.!!"$ 1+-##0'0%$.,.$!#1!1

9 Beneficiary Notices Initiative Website( 2$-5F#"$(S*.$#&*B- 6*##&$#WXU(SX6(*%C(47WXU(SX6(65%.*".(7%85#9*.&5% 6$%.$#-(85#(H&-$*-$(65%.#5B(*%C()#$0$%.&5% =(92'0,.)2($2($&#'3)&,8$&,(&#'$)%$,3,)8,58#$)($52."$L(*8)%"$,(4$V-,()%"<$ >B$".#5%&"(6B*&9(!FD9&--&5%(7%85#9*.&5% 45#9(6S!Q:PT;(7%85#9*.&5%( 45#9(6S!Q:T;;(7%85#9*.&5%( D$&#'3)&,8$&,(&#'$9,&.$%"##.$-'24:&#4$56$."#$D0#')&,($Y,(&#'$V2&)#.6$ &#'3);cG<,%-d%).#,'#,e Medicare Benefit Policy Manual Pub , Chapter 15, Section Medicare Claims Processing Manual Pub , Chapter 18, Section 30( S$C&"*#$(4$$Q45#Q!$#0&"$()#50&C$#-(V$D-&.$( This site contains detailed provider-specific information, including information about the Clinical `,52',.2'6$R##$V&"#4:8#$,(4$A++V<$ S$C&"*#$(N$*#%&%'(=$.15#3(YSN=Z( The Medicare Learning Network (MLN) is the brand name for official CMS educational products and )(92'0,.)2($92'$7#4)&,'#$9##W92'W%#'3)&#$-'23)4#'%<$R2'$,44).)2(,8$)(92'0,.)2($3)%).$."#$7#4)&,'#$`#,'()(*$ ( Beneficiary-related resources can be found in Reference F of this Guide. 1+-##0'0%$.,.$!#1!1$!!!

10 S$C&"*#$()#$0$%.&0$(!$#0&"$-(]$%$#*B(7%85#9*.&5%( SN=()#$0$%.&0$(!$#0&"$-(>CF"*.&5%*B(2$-5F#"$(V$D-&.$ =*.&5%*B(6*%"$#(7%-.&.F.$ =*.&5%*B(65##$".(65C&%'(7%&.&*.&0$(>C&.-(V$D-&.$ National Provider Identifier Information /F.+*.&$%.()#5-+$".&0$()*L9$%.(!L-.$9(7%85#9*.&5% 2$9&..*%"$(XC0&"$(7%85#9*.&5% U.S. Preventive Services Task Force (USPSTF) Guide to Clinical Preventive Services This website provides the USPSTF written recommendations.$ This site contains physician-specific information, including updates to policies (such as MPFS), '#*:8,.)2(%?$&24)(*$,(4$&23#',*#$)(92'0,.)2(?$-'2*',0$)(.#*').6$)(92'0,.)2(?$,(4$2."#'$ 3,8:,58#$'#%2:'&#%<$ ]+Y$,%%)%.%$)($."#$0,)(.#(,(&#$,(4$4)%.')5:.)2($29$I=+DDW'#8,.#4$&24#$8)%.%$.",.$,'#$#;.#'(,8$.2$."#$^EZ$ 9,0)86$29$%.,(4,'4%<$ ( Beneficiary-related resources can be found in Reference F of this Guide.!!)$ 1+-##0'0%$.,.$!#1!1