Medicare Preventive Services

Transcription

1 Medicare Preventive Services Presented by Cahaba Government Benefit Administrators, LLC Provider Outreach & Education March 24, 2010

2 Disclaimer This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited.

3 Preventive Services Initial Preventive Physical Exam Abdominal Aortic Aneurysm Screening Cardiovascular Screening Diabetes Screening Diabetes Self Management Training Medical Nutrition Therapy Screening Pap Tests and Pelvic Examinations Screening Mammograms Bone Mass Measurements Colorectal Cancer Screening Prostate Cancer Screening Glaucoma Screening Immunizations Smoking Cessation Screening EKG

4 Initial Preventive Physical Exam (IPPE) G0402 for services January 1, 2009 and after Within first 12 months of having Part B Education, counseling and referrals No deductible January 1, 2009 and after Coinsurance applies If separate Evaluation & Management service (E&M) Modifier 25

5 Screening EKG EKG portion- no longer a required part of IPPE Deductible and coinsurance do apply Use the appropriate G code G0403 Full EKG Service G0404 Technical Component only G0405 Professional Component only

6 Abdominal Aortic Aneurysm (AAA) Screening G0389 Ultrasound exam AAA screen No deductible/coinsurance does apply Must exhibit certain risk factors Must receive referral for screening as a result of IPPE Once in a lifetime benefit

7 Covered services: Cardiovascular Disease Screening Lipid Panel Cholesterol Lipoprotein Triglycerides Screening diagnosis codes V81.0, V81.1, V81.2 No Deductible or coinsurance Must be ordered by Physician Covered every 5 years

8 Diabetes Screening Blood glucose test Post-glucose dose challenge Glucose tolerance test (GTT) No deductible or coinsurance Diagnosis code V77.1 Two screening tests/year if diagnosed with pre-diabetes One screening test/year if not diagnosed with prediabetes or never tested Not covered if already diagnosed with diabetes Referral required

9 Diabetes Self-Management Training (DSMT) G0108 DSMT, individual session, per 30 minutes G0109 DSMT, group session, per 30 minutes Deductible and coinsurance apply Must exhibit risk for complications from diabetes, recently diagnosed, or previously diagnosed Up to 10 hours within 12 months Up to 2 hours in subsequent years Deductible and coinsurance apply

10 Medical Nutrition Therapy (MNT) 97802, 97803, Initial Episode G0270, G0271 Second Referral within first year Deductible and coinsurance apply Coverage for diabetes or renal disease (not receiving dialysis) Up to 3 hours in first year Up to 2 hours in subsequent years

11 Bone Mass Measurements HCPCS/CPT codes G0130, 77078, 77079, 77080, 77081, 77083, Deductible and Coinsurance apply For those at risk for Osteoporosis One measurement every 24 months More frequently if medically necessary

12 Screening Pap Test and Screening Pelvic Exam Covered for all female Medicare beneficiaries Payment every 24 months Annually, if high risk No deductible Coinsurance does apply for Pap collection and Pelvic exam No coinsurance for Pap lab test Diagnosis codes V15.89, V72.31, V76.2, V76.47, V76.49

13 Screening Mammograms CPT/HCPCS codes 77052, 77057, G0202 No deductible/coinsurance does apply Eligibility determined by age Age One Baseline screening mammography Age 40 and over Annual screening mammography Diagnosis codes V76.11 or V76.12 Modifier GG for diagnostic exam on same date

14 Colorectal Cancer Screening Fecal Occult Blood Test 82270, G0328 No Deductible or coinsurance applies Annual coverage For remainder; No deductible, Coinsurance applies. Flexible Sigmoidoscopy G0104 Covered every 4 years or once in 10 years after having a screening colonoscopy

15 Colorectal Cancer Screening Colonoscopy Every 24 months if high-risk G0105 Every 10 years if not high-risk G0121 Barium Enema Every 24 months if high-risk G0120 Every 4 years if not high-risk G0106

16 Prostate Cancer Screening Annually for men age 50 and over G0102 Digital Rectal Exam (DRE) Deductible and coinsurance apply G0103 Prostate Specific Antigen Test (PSA) No deductible or coinsurance apply Diagnosis V76.44

17 Glaucoma Screening G0117 Performed by optometrist or ophthalmologist G0118 Performed under direct supervision Deductible and coinsurance apply Covered annually if high risk Diabetes Mellitus Family History of Glaucoma African-Americans age 50 and over Hispanic-Americans age 65 and over Diagnosis V80.1

18 Adult Immunizations Flu vaccine (including H1N1) once per flu season Diagnosis V04.81 (for both), V06.6 (for seasonal flu only) Pneumococcal vaccine once per lifetime Diagnosis V03.82, V06.6 No deductible or coinsurance Hepatitis B Vaccine for High risk Scheduled doses Deductible and coinsurance apply Diagnosis V05.3

19 Immunizations Vaccine CPT/HCPCS Code(s) Influenza virus vaccine 90655, 90656, 90657, 90658, Flu administration H1N1 vaccine & administration G0008 G9141 & G9142 Pneumonia vaccine 90669, Pneumonia administration G0009 Hepatitis B vaccine 90740, 90743, 90744, 90746, Hepatitis B administration G0010

20 Smoking Cessation Counseling; intermediate, 3 to 10 minutes Counseling; intensive, greater than 10 minutes Deductible and coinsurance apply 2 quit attempts per year Maximum of 4 sessions per attempt Maximum of 8 sessions in 12 months

21 Kidney Disease Education Change Request (CR) 6557 Effective January 1, 2010 Stage IV Chronic Kidney Disease (CKD) Diagnosis sessions/lifetime coverage Deductible and coinsurance apply G0420: Educational service; individual, per one hour G0421: Educational service; group, per one hour

22 HIV Screening Effective December 8, 2009 Pub , Sections and High-risk and/or pregnant female beneficiaries Once annually if high-risk Three screenings while pregnant NEW HCPCS G0432, G0433, G0435 Diagnosis V73.89 & V69.8 or V73.89

23 Preventive Services Resources

24 Preventive Services Resources

25 Preventive Services Resources Pub Medicare Claims Processing Manual: Chapter 18 Preventive and Screening Services Pub , Medicare National Coverage Determinations Manual Sections and 210.7, HIV Testing Change Request 6557 Kidney Disease Education and Change Request 6786 Screening for HIV Infection Preventive Services Educational Products

26 Preventive Services Resources Medicare Preventive Services Medical Nutrition Therapy Benefit CMS Home Page

27 MEDICARE UPDATES

28 Contractor Updates Zone Program Integrity Contractor (ZPIC) CMS awards contract to AdvanceMed Will handle Medicare fraud and abuse complaints Medicare Contractor Provider Satisfaction Survey (MCPSS) Letters mailed to participants in January 2010 Comprehensive Error Rate Testing (CERT) November 2009 CERT Error 7.8% for all fee-for-service providers Recovery Audit Contractor (RAC) CMS approved audit issues posted on Connolly Healthcare website at

29 PECOS Update PECOS unavailable due to scheduled maintenance Use Internet-based PECOS prior to March 29,2010 or after April 5, 2010

30 SELF-SERVICE TOOLS

31 Cahaba GBA Homepage

32 Stay Informed

33 Claims Processing Log

34 Open Enrollment is Now Available! Cahaba University Enhancements

35 Resource for New Providers

36 Evaluation &Management Services Web Page

37 IVR Instructions Update

38 Which Resource Should you use before you call the Provider Contact Center? Listserv Claims Processing Log FAQ s IVR Cahaba Website Cahaba University

39 Which Resource should you use before you call the Provider Contact Center? Cahaba University Cahaba GBA website Claims Processing Log Frequently Asked Questions (FAQs) ListServ ( Notification Service) Interactive Voice Response (IVR)

40 Cahaba GBA Website Resources Cahaba Home Page Cahaba University Resource Center for New Providers Evaluation & Management Resource Center nagement_services/index.htm

41 Preventive Services Any Questions?

42 Thank You Please complete your evaluation and post-test assessment. Return via fax within the next 24 hours. Fax Number: (205)