Billing Preventive Services June 6, 2017

Transcription

1 Billing Preventive Services June 6, 2017 Disclaimer This resurce is nt a legal dcument. This presentatin was prepared as a tl t assist ur prviders. This presentatin was current at the time it was created. Althugh every reasnable effrt has been made t assure accurate infrmatin, respnsibility fr crrect claims submissin lies with the prvider f services. Reprductin f this material fr prfit is prhibited. 1

2 Alchl Misuse Screening and Cunseling All Medicare beneficiaries are eligible fr alchl screening Medicare beneficiaries wh screen psitive are eligible fr cunseling if: They are cmpetent and alert at the time cunseling is prvided and Cunseling is furnished by qualified primary care physicians r ther primary care practitiners in a primary care setting Cpayment/cinsurance/deductible waived Alchl Misuse Screening and Cunseling HCPCS/CPT Cde Definitin Frequency G0442 G0443 Annual alchl misuse screening, 15 minutes Brief face-t-face behaviral cunseling fr alchl misuse, 15 minutes Annually Fr thse wh screen psitive, 4 time per year 2

3 Annual Wellness Visit (AWV) All Medicare beneficiaries wh are bth: Nt within 12 mnths after the effective date f their first Medicare Part B cverage perid Have nt received an Initial Preventive Physical Examinatin (IPPE) r AWV within the past 12 mnths Cpayment/cinsurance/deductible waived Annual Wellness Visit (AWV) HCPCS/CPT Cde Definitin Frequency G0438 Initial visit Once in a lifetime (first AWV) G0439 Subsequent visit Annually (subsequent AWV) 3

4 Bne Mass Measurements Certain Medicare beneficiaries wh fall int at least ne f the fllwing categries: Wmen determined by their physician r qualified nn-physician practitiner (NPP) t be estrgen deficient and at a clinical risk fr steprsis Individuals with vertebral abnrmalities Individuals getting (r expecting t get) gluccrticid therapy fr mre than 3 mnths Individuals with primary hyperparathyridism Individuals being mnitred t assess respnse t U.S. Fd and Drug Administratin (FDA)- apprved steprsis drug therapy Cpayment/cinsurance/deductible waived Bne Mass Measurements HCPCS/CPT Cde Definitin Ultrasund bne density measurement interpretatin, peripheral sites, any methd Cmputed tmgraphy, bne mineral density study, 1 r mre sites; axial skeletn Dual-energy X-ray absrptimetry (DXA), bne density study, 1 r mre sites; axial skeletn DXA, bne density study, 1 r mre sites; appendicular skeletn (peripheral) G0130 Single energy X-ray absrptimetry (SEXA) bne density study, 1 r mre sites, appendicular skeletn (peripheral) Frequency: Every 2 years Mre frequently if medically necessary 4

5 Cardivascular Disease Screening Tests All Medicare beneficiaries withut apparent signs r symptms f cardivascular disease Cpayment/cinsurance/deductible waived Once every 5 years Cardivascular Disease Screening Tests HCPCS/CPT Cdes: Lipid panel. This panel must include the fllwing: chlesterl, serum, ttal Lipprtein, direct measurement, high density chlesterl (HDL chlesterl) Triglycerides ICD-10 Cdes: Z13.6 5

6 Clrectal Cancer Screening Fr clrectal cancer screening using Clguard: All Medicare beneficiaries wh fall int all f the fllwing categries: Aged 50 t 85 years Asymptmatic At average risk f develping clrectal cancer Fr screening clnscpies, FOBTs, flexible sigmidscpies, and barium enemas: All Medicare beneficiaries wh fall int at least ne f the fllwing categries: Aged 50 and lder wh are at nrmal risk f develping clrectal cancer At high risk f develping clrectal cancer Clrectal Cancer Screening Frequency Nrmal Risk Clguard Multitarget Stl DNA (sdna) Test: nce every 3 years Screening FOBT: every year Screening flexible sigmidscpy: nce every 4 years Screening clnscpy: every 10 years Screening barium enema (as an alternative t cvered screening flexible sigmidscpy) High Risk Screening FOBT: every year Screening flexible sigmidscpy: nce every 4 years Screening clnscpy: every 2 years Screening barium enema (as an alternative t cvered screening flexible sigmidscpy r clnscpy) 6

7 Clrectal Cancer Screening HCPCS/CPT Cde Definitin Anesthesia fr lwer intestinal endscpic prcedures, endscpe intrduced distal t dudenum Onclgy screening, quantitative real-time target and signal amplificatin f 10 DNA markers and fecal hemglbin, utilizing stl, algrithm reprted as a psitive r negative result Bld, ccult, by perxidase activity, qualitative; feces, cnsecutive cllected specimens with single determinatin, fr clrectal neplasm screening G0104 Flexible Sigmidscpy G0105 Clnscpy (high risk) G0106 Barium Enema (alternative t G0104) G0120 Barium Enema (alternative t G0105) G0121 Clnscpy (nt high risk) G0328 Fecal Occult Bld Test (FOBT), immunassay, 1-3 simultaneus G0464 Clrectal cancer screening; stl-based DNA and fecal ccult hemglbin Clrectal Cancer Screening Effective January 1, 2016, use CPT cde when billing fr the Clguard test. Only labratries authrized by the manufacturer t perfrm the Clguard test may bill fr this test. Fr Clguard Multitarget Stl DNA (sdna) Test, use ICD-10 cdes Z12.11 and Z

8 Clrectal Cancer Screening 81528, 82270, G0104, G0105, G0121, G0328, and G0464 Cpayment/cinsurance/deductible waived Append mdifier 33 t the anesthesia CPT cde when yu furnish a separately payable anesthesia service in cnjunctin with a screening clnscpy t waive Medicare beneficiary cpayment/cinsurance and deductible G0106 and G0120 Cpayment/cinsurance applies Deductible waived N deductible fr all surgical prcedures furnished n the same date and in the same encunter as a screening clnscpy, flexible sigmidscpy, r barium enema initiated as a clrectal cancer screening services Append mdifier PT t CPT cde in the surgical range n t in this scenari Cunseling t Prevent Tbacc Use Outpatient and hspitalized Medicare beneficiaries fr whm all f the fllwing are true: Use tbacc, regardless f whether they exhibit signs r symptms f tbacc-related disease Cmpetent and alert at the time f cunseling Cunseling furnished by a qualified physician r ther Medicarerecgnized practitiner Cpayment/cinsurance/deductible waived fr and Tw cessatin attempts per year Each attempt may include a maximum f 4 intermediate r intensive sessins, with the ttal annual benefit cvering up t 8 sessins per year 8

9 Cunseling t Prevent Tbacc Use HCPCS/CPT Cde Definitin Smking and tbacc-use cessatin cunseling visit; intermediate, greater than 3 minutes up t 10 minutes Smking and tbacc-use cessatin cunseling visit; intensive, greater than 10 minutes ICD-10 Cdes F17.200, F17.201, F17.210, F17.211, F17.220, F17.290, F17.291, T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.394A, and Z Additinal ICD-10 cdes may apply Depressin Screening All Medicare beneficiaries Must be furnished in a primary care setting that gas staff-assisted depressin care supprts in place t assure accurate diagnsis, effective treatment, and fllw-up Annually Cpayment/cinsurance/deductible waived G0444- Annual depressin screening, 15 minutes 9

10 Diabetes Screening Medicare beneficiaries with certain risk factrs fr diabetes r diagnsed with pre-diabetes Medicare beneficiaries previusly diagnsed with diabetes are nt eligible fr this benefit Cpayment/cinsurance/deductible waived Append mdifier TS when submitting claims fr beneficiaries with prediabetes Tw screening tests per year fr Medicare beneficiaries diagnsed with pre-diabetes One screening per year if previusly tested but nt diagnsed with pre-diabetes r if never tested HCPCS/CPT Cde Diabetes Screening Definitin Glucse; quantitative, bld (except reagent strip) Glucse; pst glucse dse (includes glucse) Glucse; tlerance test (GTT), 3 specimens (includes glucse) ICD-10 Cdes Z

11 Diabetes Self-Management Training (DSMT) Certain Medicare beneficiaries when all f the fllwing are true: Diagnsed with diabetes Receive an rder fr DSMT frm the physician r qualified NPP treating the Medicare beneficiary s diabetes Cpayment/cinsurance/deductible apply Initial year Up t 10 hurs f initial training within a cntinuus 12-mnth perid Subsequent years Up t 2 hurs f fllw-up training each year after the initial year Diabetes Self-Management Training (DSMT) HCPCS/CPT Cde G0108 G0109 Definitin DSMT, individual, per 30 minutes DSMT, grup (2 r mre), per 30 minutes 11

12 Glaucma Screening Medicare beneficiaries wh fall int at least ne f the fllwing categries: Have diabetes mellitus Have a family histry f glaucma Are African-Americans aged 50 and lder Are Hispanic-Americans aged 65 and lder Cpayment/cinsurance/deductible apply Annually Glaucma Screening HCPCS/CPT Cde G0117 G0118 Definitin By an ptmetrist r phthalmlgist Under the direct supervisins f an ptmetrist r phthalmlgist ICD-10 Cdes Z

13 Hepatitis B Virus (HBV) Vaccine Certain Medicare beneficiaries at intermediate r high risk fr cntracting hepatitis B Medicare beneficiaries wh are currently psitive fr antibdies fr hepatitis B are nt eligible fr this benefit Scheduled dsages required Cpayment/cinsurance/deductible waived Hepatitis B Virus (HBV) Vaccine HCPCS/CPT Cde Definitin Hepatitis B vaccine, adult dsage (2 dse schedule), fr intramuscular use Hepatitis B vaccine, dialysis r immunsuppressed patient dsage (3 dse schedule), fr intramuscular use Hepatitis B vaccine, adlescent (2 dse schedule), fr intramuscular use Hepatitis B vaccine, pediatric/adlescent dsage (3 dse schedule), fr intramuscular use Hepatitis B vaccine, adult dsage (3 dse schedule), fr intramuscular use Hepatitis B vaccine, dialysis r immunsuppressed patient dsage (4 dse schedule), fr intramuscular use G0010 Administratin f Hepatitis B vaccine ICD-10 Cde: Z23 13

14 Hepatitis C Virus (HCV) Screening Certain adult Medicare beneficiaries wh fall int at least ne f the fllwing categries: High risk fr HCV infectin Brn between 1945 and 1965 Cpayment/cinsurance/deductible waived Annually: nly fr high risk beneficiaries with cntinued illicit injectin drug use since the prir negative screening test Once in a lifetime: fr beneficiaries brn between 1945 and 1965 wh are nt cnsidered high risk G0472- Hepatitis C antibdy screening, fr individual at high risk r ther cvered indicatins ICD-10 cdes: Z72.89 F19.20 Human Immundeficiency Virus (HIV) Screening Certain Medicare beneficiaries wh are at increased risk fr HIV infectin, including anyne wh asks fr the test, r pregnant wmen Cpayment/cinsurance/deductible waived Annually fr beneficiaries between the ages f 15 and 65 withut regard fr perceived risk Annually fr beneficiaries yunger than 15 and adults lder than 65 wh are at an increased risk fr HIV infectin 3 times per pregnancy 14

15 Human Immundeficiency Virus (HIV) Screening HCPCS/CPT Cde Definitin Obstetric panel (includes HIV testing) G0432 G0433 G0435 G0475 Infectius agent antibdy detectin by EIA technique Infectius agent antibdy detectin by ELISA technique Infectius agent antibdy detectin by rapid antibdy test HIV antigen/antibdy, cmbinatin assay, screening ICD-10 Cdes Scenari Z11.4 Increased risk factrs nt reprted Z11.4 and Z72.89, Z72.51, Z72.52, r Z72.53 Increased risk factrs reprted Z11.4 and Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, r O09.93 Pregnant beneficiaries Influenza Virus Vaccine All Medicare beneficiaries Cpayment/cinsurance/deductible waived Once per influenza seasn Cverage fr additinal flu shts if medically necessary Influenza Virus vaccine 90630, 90653, 90654, 90655, 90656, 90657, 90661, 90662, 90672, 90673, 90674, 90685, 90686, 90688, Q2035, Q2036, Q2037, Q2038, Q2039 Administratin f influenza virus vaccine G0008 ICD-10 Cde Z23 15

16 Initial Preventive Physical Examinatin (IPPE) Welcme t Medicare Preventive Visit All new Medicare beneficiaries wh are within the first 12 mnths f their first Medicare Part B cverage perid Once in a lifetime Must furnish n later than 12 mnths after the effective date f the first Medicare Part B cverage perid Initial Preventive Physical Examinatin (IPPE) HCPCS/CPT Cde Definitin Beneficiary Pays G0402 IPPE Cpayment/Cinsurance /Deductible Waived G0403 EKG fr IPPE Cpayment/Cinsurance /Deductible Applies G0404 EKG tracing fr IPPE Cpayment/Cinsurance /Deductible Applies G0405 EKG interpret & reprt fr IPPS Cpayment/Cinsurance /Deductible Applies 16

17 Intensive Behaviral Therapy (IBT) fr Obesity Medicare beneficiaries when all f the fllwing are true: Obesity Cmpetent and alert at the time cunseling is prvided Cunseling furnished by a qualified primary care physician r ther primary care practitiner in a primary care setting Cpayment/cinsurance/deductible waived First mnth One face-t-face visit every week Mnths 2-6 Once face-t-face visit every ther week Mnths 7-12 One face-t-face visit every mnth if certain requirements are met Intensive Behaviral Therapy (IBT) fr Obesity HCPCS/CPT Cde G0447 Definitin Face-t-face behaviral cunseling fr besity, 15 minutes G0473 Face-t-face behaviral cunseling fr besity, grup (2-10), 30 minutes ICD-10 Cdes: Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38, Z68.39, Z68.41, Z68.42, Z68.43, Z68.44, r Z

18 Lung Cancer Screening Cunseling and Annual Screening fr Lung Cancer with LDCT Lw Dse Cmputed Tmgraphy (LDCT) Medicare beneficiaries wh fall int all f the fllwing categries: Age years Asymptmatic Tbacc smking histry f at least 30 pack-years Current smker r ne wh has quit smking within the last 15 years Receive a written rder fr lung cancer screening with LDCT Cpayment/cinsurance/deductible waived Annually First year: befre the first lung cancer LDCT screening, must receive a cunseling and shared decisin making visit Subsequent years: receive a written rder furnished during an apprpriate visit with a physician r NPP Lung Cancer Screening Cunseling and Annual Screening fr Lung Cancer with LDCT HCPCS/CPT Cde Definitin G0296 G0297 Cunseling visit t discuss need fr lung cancer screening (LDCT) using lw des CT scan Lw dse CT scan (LDCT) fr lung cancer screening ICD-10 Cde: Z

19 Medical Nutritin Therapy (MNT) Certain Medicare beneficiaries when all f the fllwing are true: Receive a referral frm their treating physician Diagnsed with diabetes r renal disease, r wh have received a kidney transplant within the last 3 years Service prvided by a registered dietitian r nutritin prfessinal Cpayment/cinsurance/deductible waived First year 3 hurs f ne-n-ne cunseling Subsequent years 2 hurs Medical Nutritin Therapy (MNT) HCPCS/CPT Cde Definitin MNT; initial assessment and interventin, individual, face-t-face with the patient, each 15 minutes MNT; reassessment and interventin, individual, face-tface with the patient each 15 minutes MNT; grup (2 r mre individuals), each 30 minutes G0270 G0271 MNT reassessment and subsequent interventins fr change in diagnsis, medical cnditin r treatment regimen, each 15 minutes MNT reassessment and subsequent interventins fr change in diagnsis, medical cnditin r treatment regimen, grup (2 r mre), each 30 minutes 19

20 Pneumcccal Vaccine All Medicare beneficiaries Cpayment/cinsurance/deductible waived An initial pneumcccal vaccine t beneficiaries wh never received the vaccine under Medicare Part B A different, secnd pneumcccal vaccine 1 year after the first vaccine was administered Pneumcccal Vaccine HCPCS/CPT Cde Definitin Pneumcccal Cnjugate Vaccine Pneumcccal plysaccharide vaccine G0009 Administratin ICD-10 Cde Z23 20

21 Prstate Cancer Screening All male Medicare beneficiaries aged 50 and lder Annually HCPCS/CPT Cde G0102 G0103 Definitin Digital Rectal Exam (DRE) Prstate Specific Antigen Test (PSA) Beneficiary Pays Cpayment/Cinsurance/Dedu ctible Applies Cpayment/Cinsurance/Dedu ctible Waived ICD-10 Cde Z12.5 Screening fr Cervical Cancer with HPV Tests All asymptmatic female Medicare beneficiaries aged 30 t 65 years Once every 5 years Cpayment/cinsurance/deductible waived G0476 Cervical cancer screening, all inclusive HPV c-test with cytlgy (Pap smear) t detect HPV DNA r RNA sequences Use either f the fllwing ICD-10 cdes: Encunter fr screening fr HPV- Z11.51 and Encunter fr gyneclgical exam (general) (rutine) with abnrmal findings- Z Encunter fr gyneclgical exam (general) (rutine) withut abnrmal findings- Z

22 Screening fr STIs and HIBC t Prevent STIs Sexually Transmitted Infectins (STIs) High Intensity Behaviral Cunseling (HIBC) Certain Medicare beneficiaries when all f the fllwing are true: Sexually active adlescents and adults at increased risk fr STIs Referred fr this service by a primary care prvider and prvided by a Medicare-eligible primary care prvider in a primary care setting Cpayment/cinsurance/deductible waived Screening fr STIs and HIBC t Prevent STIs Frequency: One annual ccurrence f screening fr chlamydia, gnrrhea, and syphilis in wmen at increased risk wh are nt pregnant One annual ccurrence f screening fr syphilis in men at increased risk Up t tw ccurrences per pregnancy f screening fr chlamydia and gnrrhea in pregnant wmen wh are at increased risk fr STIs and cntinued increased risk fr the secnd screening One ccurrence per pregnancy f screening fr syphilis in pregnancy wmen; up t tw additinal ccurrences in the third trimester and at delivery if at cntinued increased risk fr STIs One ccurrence per pregnancy f screening fr hepatitis B in pregnant wmen; ne additinal ccurrence at deliver if at cntinued increased risk fr STIs Up t tw minute, face-t-face HIBC sessins annually 22

23 Screening fr STIs and HIBC t Prevent STIs HCPCS/CPT Cdes 86631, 86632, 87110, 87270, 87320, 87490, 87491, Definitin Chlamydia 87590, 87591, Neisseria gnrrheae Infectius agent detectin by nucleic acid, multiple rganisms; direct prbe technique Syphilis test, n-trepnemal antibdy; qualitative Syphilis test, nn-trepnemal, quantitative Trepnema pallidum 87340, Hepatitis B (hepatitis B surface antigen) G0445 Semiannual high intensity behaviral cunseling t prevent STIs, individual, face-t-face, includes educatin skills training & guidance n hw t change sexual behavir, 30 minutes Screening fr STIs and HIBC t Prevent STIs ICD-10 Cdes Z11.3, Z72.89, Z72.51, Z72.52, Z72.53, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, and O

24 Screening Mammgraphy All female Medicare beneficiaries aged 35 and lder Aged 35 thrugh 39 One baseline Aged 40 and lder Annually Cpayment/cinsurance/deductible waived If billing a screening mammgram and a diagnstic mammgram n the same day, use mdifier GG t shw a screening mammgram turned int a diagnstic mammgram Screening Mammgraphy HCPCS/CPT Cde Definitin Cmputer-aided detectin with further review fr interpretatin; screening mammgraphy (List separately in additin t cde fr primary prcedure) Screening mammgraphy, bilateral (2-view film study f each breast) Screening digital breast tmsynthesis; bilateral (List separately in additin t cde fr primary prcedure) (Use this as an add-n cde t G0202 when tmsynthesis is used in additin t 2-D mammgraphy) G0202 Screening mammgraphy, prducing direct 2-D digital image, bilateral, all views ICD-10 Cde Z

25 Screening Pap Tests All female Medicare beneficiaries Cpayment/cinsurance/deductible waived Annually if at high risk fr develping cervical r vaginal cancer r childbearing age with abnrmal Pap test within past 3 years Every 2 years fr wmen at nrmal risk ICD-10 Cdes: High risk- Z77.21, Z77.22, Z77.9, Z91.89, Z92.89, Z72.51, Z72.52, and Z72.53 Lw risk- Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z12.89 Screening Pap Tests HCPCS/CPT Cdes G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148 P3000 P3001 Q0091 Definitin Screening cytpathlgy, cervical r vaginal Screening Pap smear by technician under physician supervisin Screening Pap smear requiring interpretatin by physician Screening Pap smear; btaining, preparing and cnveyance t lab 25

26 Screening Pelvic Examinatins Includes a clinical breast examinatin All female Medicare beneficiaries Cpayment/cinsurance/deductible waived Annually if at high risk fr develping cervical r vaginal cancer r childbearing age with abnrmal Pap test within past 3 years Every 2 years fr wmen at nrmal risk Screening Pelvic Examinatins G0101- Cervical r vaginal cancer screening; pelvic and clinical breast examinatin ICD-10 Cdes: High risk- Z77.22, Z77.9, Z91.89, Z72.89, Z72.51, Z72.52, and Z72.53 Lw risk- Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z

27 Ultrasund Screening fr Abdminal Artic Aneurysm (AAA) Medicare beneficiaries when all f the fllwing are true: Certain risk factrs fr AAA Receive a referral frm their physician, physician assistant, nurse practitiner, r clinical nurse specialist Once in a lifetime Cpayment/cinsurance/deductible waived G0389- Ultrasund exam fr AAA screening ELGA Eligibility HETS (CMS HIPAA Eligibility Transactin System) IVR (Interactive Vice Respnse) InSite S&SWEH=insite.cahabagba.cm 27

28 Resurces Medicare Preventive Services s/mps-quickreferencechart-1textonly.pdf Medicare Preventive Services Quick Reference Chart Preventive Services Webpage CMS Prvider Minute: Preventive Services Thank Yu fr Attending! Please cmplete the evaluatin! 28