Alcohol Misuse Screening and Counseling

Transcription

1 Page 1 of 38 Alcohol Misuse Screening and Counseling Also referred to as the Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse G0442 Annual alcohol misuse screening, 15 minutes G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes See the CMS ICD-10 webpage ( for individual Change Requests (CRs) and coding translations for ICD-10, and contact your Medicare Administrative Contractor (MAC) ( Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map) for guidance All Medicare beneficiaries are eligible for alcohol screening. Medicare beneficiaries are eligible for counseling if they: Screen positive (those who misuse alcohol but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence) Are competent and alert at the time counseling is provided Get counseling from qualified primary care physicians or other primary care practitioners in a primary care setting Annually for G0442 (screening) For those who screen positive, 4 times per year for G0443 (counseling)

2 Page 2 of 38 Annual Wellness Visit (AWV) G0438 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit G0439 Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure) See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Programs/Review-Contractor-Directory-Interactive-Map) All Medicare beneficiaries who: for guidance Are not within 12 months after the effective date of their first Medicare Part B coverage period and Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months Once in a lifetime for G0438 (first AWV) Annually for G0439 (subsequent AWV) Annually for optional 99497, 99498

3 Page 3 of 38 G0438 and G0439: and 99498: Copayment/coinsurance and deductible waived for Advance Care Planning when furnished as an optional element of an AWV For services furnished on or after January 1, 2016, Advance Care Planning ( Publications-Items/ICN html) is treated as an optional preventive service when furnished with an AWV. Practitioners may provide Advance Care Planning outside of the AWV multiple times in a year, but the practitioner must document a change in the beneficiary s health for each additional service in a year. When providing Advance Care Planning outside the AWV, the beneficiary is responsible for the deductible and coinsurance. The deductible and coinsurance for Advance Care Planning is only waived when furnished as an optional element of an AWV ( Network-MLN/MLNMattersArticles/Downloads/MM9271.pdf), which requires: Billing with modifier 33 (Preventive Service) on the same claim as an AWV Furnishing on the same day and by the same provider as the AWV Refer to The ABCs of the Annual Wellness Visit ( Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS html) for more information. CPT only copyright 2018 American Medical Association. All rights reserved. Bone Mass Measurements Ultrasound bone density measurement and interpretation, peripheral site(s), any method Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) 77081

4 Page 4 of 38 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment G0130 Single energy x-ray absorptiometry (sexa) bone density study, 1 or more sites, appendicular skeleton (peripheral) (eg, radius, wrist, heel) M81.0, M81.6, M81.8, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M85.88, M85.89, M89.9, M94.9 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. Certain Medicare beneficiaries who fall into at least one of the following categories: Women determined by their physician or qualified nonphysician practitioner (NPP) to be estrogen deficient and at clinical risk for osteoporosis Individuals with vertebral abnormalities Individuals getting (or expecting to get) glucocorticoid therapy for more than 3 months Individuals with primary hyperparathyroidism Individuals being monitored to assess response to U.S. Food and Drug Administration (FDA)-approved osteoporosis drug therapy Every 2 years More frequently if medically necessary Refer to the current codes in the ICD-10 Conversion/Coding Infrastructure Revisions to National Coverage Determinations (NCDs)--3rd Maintenance ( Guidance/Guidance/Transmittals/Downloads/R1580OTN.pdf) for reporting frequency requirements with respect to specific ICD-10 codes

5 Page 5 of 38 Do not report with or Do not report with or Do not report with or Medicare does not cover for this service. When coding and together, attach modifier XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service) to to bypass Correct Coding Initiative edit. When coding and together, attach modifier XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service) to CPT only copyright 2018 American Medical Association. All rights reserved. Cardiovascular Disease Screening Tests Lipid panel: This panel must include the following: Z Cholesterol, serum, total Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) Triglycerides Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. All Medicare beneficiaries without apparent signs or symptoms of cardiovascular disease

6 Page 6 of 38 Once every 5 years CPT only copyright 2018 American Medical Association. All rights reserved. Colorectal Cancer Screening Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection) G0104 Colorectal cancer screening; flexible sigmoidoscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0106 Colorectal cancer screening; alternative to g0104, screening sigmoidoscopy, barium enema G0120 Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Programs/Review-Contractor-Directory-Interactive-Map) For multitarget sdna test, use Z12.11 and Z12.12 for guidance

7 Page 7 of 38 For colorectal cancer screening using multitarget sdna test: All Medicare beneficiaries who fall into all of the following categories: Aged 50 to 85 years Asymptomatic At average risk of developing colorectal cancer For screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas: All Medicare beneficiaries who fall into at least one of the following categories: Aged 50 and older who are at normal risk of developing colorectal cancer At high risk of developing colorectal cancer High risk for developing colorectal cancer is defined in the Code of Federal Regulations (CFR) at 42 CFR ( vol2/pdf/cfr-2016-title42-vol2-sec pdf) (a)(3) Coverage of screening colonoscopies has no age limitation For Beneficiaries Not Meeting Criteria for High Risk: Multitarget sdna test: once every 3 years Screening FOBT: once every 12 months Screening flexible sigmoidoscopy: once every 48 months (unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer and the beneficiary has had a screening colonoscopy within the preceding 10 years, in which case Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that the beneficiary received the screening colonoscopy) Screening colonoscopy: once every 120 months (10 years), or 48 months after a previous sigmoidoscopy Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy): once every 48 months For Beneficiaries at High Risk: Screening FOBT: once every 12 months Screening flexible sigmoidoscopy: once every 48 months Screening colonoscopy: once every 24 months (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after at least 47 months)

8 Page 8 of 38 Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy): once every 24 months 81528, 82270, G0104, G0105, G0121, and G0328: G0106 and G0120: Copayment/coinsurance applies No deductible applies for all surgical procedures (CPT code range of to 69999) furnished on the same date and in the same encounter as a screening colonoscopy, flexible sigmoidoscopy, or barium enema initiated as colorectal cancer screening services. Append modifier PT to CPT code in the surgical range of to in this scenario. Effective January 1, 2016, CPT code replaced HCPCS G0464 for the Cologuard multitarget stool DNA (sdna) test ( Network-MLN/MLNMattersArticles/Downloads/MM9115.pdf). Append modifier 33 (Preventive Service) to the anesthesia CPT code ( MLN/MLNMattersArticles/Downloads/MM8874.pdf) when you furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (G0105 and G0121) to waive Medicare beneficiary copayment/coinsurance and deductible. When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia code should be submitted with only the PT modifier, and only the deductible will be waived. Append modifier 33 (Preventive Service) or PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) to the moderate sedation codes G0500 and ( MLN/MLNMattersArticles/Downloads/MM10075.pdf) when you furnish moderate sedation in conjunction with screening colonoscopy services to waive Medicare beneficiary copayment/coinsurance and deductible. CPT only copyright 2018 American Medical Association. All rights reserved.

9 Page 9 of 38 Counseling to Prevent Tobacco Use Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, 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, T65.294A, and Z Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. Outpatient and hospitalized Medicare beneficiaries for whom all of the following are true: Use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease Competent and alert at the time of counseling Counseling furnished by a qualified physician or other Medicare-recognized practitioner Two cessation attempts per year. Each attempt may include a maximum of 4 intermediate or intensive sessions, with the total annual benefit covering up to 8 sessions per year.

10 Page 10 of 38 Effective September 30, 2016, HCPCS codes G0436 and G0437 are deleted. Use existing CPT codes and for smoking and tobacco-use cessation counseling visits. CPT only copyright 2018 American Medical Association. All rights reserved. Depression Screening G0444 Annual depression screening, 15 minutes See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Programs/Review-Contractor-Directory-Interactive-Map) All Medicare beneficiaries for guidance Annually Screening must be furnished in primary care settings with staff-assisted depression care supports in place to ensure accurate diagnosis, effective treatment, and follow-up

11 Page 11 of 38 Diabetes Screening Glucose; quantitative, blood (except reagent strip) Glucose; post glucose dose (includes glucose) Glucose; tolerance test (GTT), 3 specimens (includes glucose) Z13.1 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. Medicare beneficiaries with certain risk factors for diabetes or diagnosed with pre-diabetes Medicare beneficiaries previously diagnosed with diabetes are not eligible for this benefit One screening every 6 months for Medicare beneficiaries diagnosed with pre-diabetes One screening every 12 months if previously tested but not diagnosed with pre-diabetes or if never tested Append modifier TS (Follow-up service) when submitting claims for Medicare beneficiaries with pre-diabetes

12 Page 12 of 38 Medicare only pays claims for Durable Medicare Equipment (DME) if the ordering provider and DME supplier are actively enrolled in Medicare on the date of service or, in the case of the provider, have a valid opt-out affidavit on file. Tell your Medicare patients if you are not participating in Medicare before you order DME. Refer to Medicare Enrollment for Providers Who Solely Order, Certify, or Prescribe ( Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS html) for information on how to enroll as an ordering, certifying, or prescribing provider. CPT only copyright 2018 American Medical Association. All rights reserved. Diabetes Self-Management Training (DSMT) G0108 Diabetes outpatient self-management training services, individual, per 30 minutes G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Programs/Review-Contractor-Directory-Interactive-Map) for guidance Certain Medicare beneficiaries when all of the following are true: Diagnosed with diabetes Received an order for DSMT from the physician or qualified NPP treating the Medicare beneficiary's diabetes Initial year: Up to 10 hours of initial training within a continuous 12-month period Subsequent years: Up to 2 hours of follow-up training each calendar year after the initial 10 hours of training has been completed

13 Page 13 of 38 Copayment/coinsurance applies Deductible applies Refer to Provider Compliance Tips for Diabetic Test Strips ( Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN html) for more information You cannot bill DSMT and Medical Nutrition Therapy (MNT) on the same date of service for the same beneficiary For information on accreditation, see the DSMT Accreditation Program webpage ( Accreditation-Program.html) Glaucoma Screening G0117 Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist G0118 Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist Z13.5 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. Medicare beneficiaries who fall into at least one of the following high risk categories: Individuals with diabetes mellitus Individuals with a family history of glaucoma African-Americans aged 50 and older

14 Page 14 of 38 Hispanic-Americans aged 65 and older Annually Copayment/coinsurance applies Deductible applies Hepatitis B Virus (HBV) Screening For Asymptomatic, Nonpregnant Adolescents and Adults at High Risk G0499 Hepatitis b screening in non-pregnant, high risk individual includes hepatitis b surface antigen (hbsag) followed by a neutralizing confirmatory test for initially reactive results, and antibodies to hbsag (anti-hbs) and hepatitis b core antigen (anti-hbc) For Pregnant Women Hepatitis B core antibody (HBcAb); total Hepatitis B surface antibody (HBsAb) Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiplestep method; hepatitis B surface antigen (HBsAg) Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiplestep method; hepatitis B surface antigen (HBsAg) neutralization For Asymptomatic, Nonpregnant Adolescents and Adults at High Risk Z11.59 and Z72.89 For Asymptomatic, Nonpregnant Adolescents and Adults, Subsequent Visits

15 Page 15 of 38 Z11.59 and one of the following: F11.10 F11.99, F13.10 F13.99, F14.10 F14.99, F15.10 F15.99, Z20.2, Z20.5, Z72.52, Z72.53 For Pregnant Women Z11.59 and one of the following: Z34.00, Z34.80, Z34.90, O09.90 For Pregnant Women at High Risk Z11.59 andz72.89 and one of the following: 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, O09.93 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. Certain Medicare beneficiaries who fall into any of the following categories: Asymptomatic, nonpregnant adolescents and adults at high risk for HBV infection Pregnant women High risk is defined in the Medicare National Coverage Determinations Manual, Chapter 1, Part 4 ( Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf), Section Screening for Hepatitis B Virus (HBV) Infection One screening for asymptomatic, nonpregnant adolescents and adults who do not meet the high risk definition Annually only for those who have continued high risk who do not receive hepatitis B vaccination One screening for pregnant women at the first prenatal visit for each pregnancy and rescreening at the time of delivery for those with new or continued risk factors This includes screening during the first prenatal visit in subsequent pregnancies, regardless of previous HBV vaccination or previous negative hepatitis B surface antigen test results

16 Page 16 of 38 Refer to Screening for Hepatitis B Virus (HBV) Infection ( Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9859.pdf) for more information CPT only copyright 2018 American Medical Association. All rights reserved. Hepatitis B Virus (HBV) Vaccine and Administration Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for intramuscular use Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule, for intramuscular use G0010 Administration of hepatitis b vaccine Z23 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. Certain Medicare beneficiaries at intermediate or high risk for contracting hepatitis B Intermediate and high risk is defined in the Medicare Benefit Policy Manual, Chapter 15 ( Section Immunizations

17 Page 17 of 38 Medicare beneficiaries who are currently positive for antibodies for hepatitis B are eligible not for this benefit Scheduled dosages required Effective for dates of service on or after October 1, 2016, Medicare hospice providers may bill for vaccine services on institutional claims ( Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9052.pdf) Refer to Medicare Part B Immunization Billing ( Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS html) for more information CPT only copyright 2018 American Medical Association. All rights reserved. Hepatitis C Virus (HCV) Screening G0472 Hepatitis c antibody screening, for individual at high risk and other covered indication (s) Z72.89 and F19.20 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance.

18 Page 18 of 38 Certain adult Medicare beneficiaries who fall into at least one of the following categories: High risk for HCV infection Born between 1945 and 1965 Had a blood transfusion before 1992 Intermediate and high risk is defined in the Medicare National Coverage Determinations Manual, Chapter 1, Part 4 ( Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf), Section Screening for Hepatitis C Virus (HCV) in Adults Once for Medicare beneficiaries born from 1945 through 1965 who are not considered high risk (use ICD-10 Z11.59; effective October 1, 2017) An initial screening for Medicare beneficiaries, regardless of birth year, for adults at high risk, that is, beneficiaries who had a blood transfusion before 1992 and beneficiaries with a current or past history of illicit injection drug use Annually only for high risk Medicare beneficiaries with continued illicit injection drug use since the prior negative (HCV) screening test Refer to Screening for Hepatitis C Virus (HCV) in Adults ( Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8871.pdf) for more information Human Immunodeficiency Virus (HIV) Screening Obstetric panel (includes HIV testing) G0432 Infectious agent antibody detection by enzyme immunoassay (eia) technique, hiv-1 and/or hiv-2, screening G0433 Infectious agent antibody detection by enzyme-linked immunosorbent assay (elisa) technique, hiv-1 and/or hiv-2, screening

19 Page 19 of 38 G0435 Infectious agent antibody detection by rapid antibody test, hiv-1 and/or hiv-2, screening G0475 Hiv antigen/antibody, combination assay, screening Increased risk factors not reported - Z11.4 Increased risk factors reported - Z11.4 and Z72.51, Z72.52, Z72.53, or Z72.89 Pregnant Medicare beneficiaries - 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, or O09.93 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. Certain Medicare beneficiaries without regard to perceived risk or who are at increased risk for HIV infection, including anyone who asks for the test, or pregnant women Increased risk for HIV infection is defined in the Medicare National Coverage Determinations Manual, Chapter 1, Part 4 ( Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf), Section Annually for Medicare beneficiaries between the ages of 15 and 65 without regard to perceived risk Annually for Medicare beneficiaries younger than 15 and adults older than 65 who are at increased risk for HIV infection For Medicare beneficiaries who are pregnant, 3 times per pregnancy First, when a woman is diagnosed with pregnancy Second, during the third trimester Third, at labor, if ordered by the woman s clinician

20 Page 20 of 38 Refer to Screening for the Human Immunodeficiency Virus (HIV) Infection ( MLN/MLNMattersArticles/Downloads/MM9403.pdf) for more information CPT only copyright 2018 American Medical Association. All rights reserved. Influenza Virus Vaccine and Administration Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 ml dosage, for intramuscular use Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 ml dosage, for intramuscular use Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 ml dosage, for intramuscular use Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use Influenza virus vaccine, trivalent (cciiv3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 ml dosage, for intramuscular use Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use Influenza virus vaccine, quadrivalent (cciiv4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 ml dosage, for intramuscular use Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 ml dosage, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 ml dosage, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 ml dosage, for intramuscular use

21 Page 21 of Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 ml dosage, for intramuscular use 90756* Influenza virus vaccine, quadrivalent (cciiv4), derived from cell cultures, subunit, antibiotic free, 0.5 ml dosage, for intramuscular use (*Effective for dates of service on or after January 1, 2018, see the Quarterly Influenza Virus Vaccine Code Update January 2018 ( Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10196.pdf) ) Q2034 Influenza virus vaccine, split virus, for intramuscular use (agriflu) Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (afluria) Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (flulaval) Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluvirin) Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluzone) Q2039** Influenza virus vaccine, not otherwise specified (**Effective for dates of service from August 1, 2017, through December 31, 2017; replaced by effective January 1, 2018, see the Quarterly Influenza Virus Vaccine Code Update January 2018 ( Learning-Network-MLN/MLNMattersArticles/Downloads/MM10196.pdf) ) G0008 Administration of influenza virus vaccine Z23 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. All Medicare beneficiaries Once per influenza season Medicare covers additional flu shots if medically necessary

22 Page 22 of 38 Effective for dates of service on or after October 1, 2016, Medicare hospice providers may bill for vaccine services on institutional claims ( Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9052.pdf) CPT only copyright 2018 American Medical Association. All rights reserved. Initial Preventive Physical Examination (IPPE) Also known as the Welcome to Medicare Preventive Visit G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report G0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination G0405 Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC Refer to Medicare Part B Immunization Billing ( Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS html) and Influenza (Flu) Resources for Health Care Professionals ( MLN/MLNMattersArticles/Downloads/SE17026.pdf) for more information ( Programs/Review-Contractor-Directory-Interactive-Map) for guidance

23 Page 23 of 38 All new Medicare beneficiaries who are within the first 12 months of their first Medicare Part B coverage period Once in a lifetime Must furnish no later than 12 months after the effective date of the first Medicare Part B coverage period G0402: G0403, G0404, and G0405: Copayment/coinsurance applies Deductible applies Refer to The ABCs of the Initial Preventive Physical Examinations (IPPE) ( Publications-Items/CMS html) for more information Intensive Behavioral Therapy (IBT) for Cardiovascular Also known as a CVD risk reduction visit G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

24 Page 24 of 38 See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Programs/Review-Contractor-Directory-Interactive-Map) All Medicare beneficiaries who are: for guidance Competent and alert at the time counseling is provided Furnished counseling by a qualified primary care physician or other primary care practitioner and in a primary care setting Annually Intensive Behavioral Therapy (IBT) for Obesity G0447 Face-to-face behavioral counseling for obesity, 15 minutes G0473 Face-to-face behavioral counseling for obesity, group (2 10), 30 minutes 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, or Z68.45 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance.

25 Page 25 of 38 Medicare beneficiaries when all of the following are true: Obesity (Body Mass Index [BMI] 30 kilograms [kg] per meter squared) Competent and alert at the time counseling is provided Counseling furnished by a qualified primary care physician or other primary care practitioner in a primary care setting Medicare will pay for up to 22 visits billed with the codes G0447 and G0473, combined, in a 12-month period: First month: one face-to-face visit every week Months 2 6: one face-to-face visit every other week Months 7 12: one face-to-face visit every month if certain requirements are met At the 6-month visit, a reassessment of obesity ( Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7641.pdf) and a determination of the amount of weight loss must be performed. To be eligible for additional face-to-face visits occurring once a month for months 7 12, Medicare beneficiaries must have lost at least 3 kg during the first 6 months For Medicare beneficiaries who do not achieve a weight loss of at least 3 kg during the first 6 months, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period Lung Cancer Screening Counseling and Annual Screening for Lung Cancer With Low Dose Computed Tomography (LDCT) G0296 Counseling visit to discuss need for lung cancer screening using low dose ct scan (ldct) (service is for eligibility determination and shared decision making) G0297 Low dose ct scan (ldct) for lung cancer screening

26 Page 26 of 38 F17.210, F17.211, F17.213, F17.218, F17.219, Z Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. Medicare beneficiaries who meet all of the following categories: Aged 55 through 77 Asymptomatic (no signs or symptoms of lung cancer) Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes) Current smoker or one who has quit smoking within the last 15 years Receive a written order for lung cancer screening with LDCT that meets the requirements described in the National Coverage Determinations Manual, Chapter 1, Part 4 ( Section Annually for covered Medicare beneficiaries: First year: Before the first lung cancer LDCT screening, Medicare beneficiaries must receive a counseling and shared decision making visit Subsequent years: The Medicare beneficiary must receive a written order furnished during any appropriate visit with a physician or qualified NPP Refer to Medicare Coverage of Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) ( MLN/MLNMattersArticles/Downloads/mm9246.pdf) for more information

27 Page 27 of 38 Medical Nutrition Therapy (MNT) Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Programs/Review-Contractor-Directory-Interactive-Map) for guidance Certain Medicare beneficiaries when all of the following are true: Receive a referral from their treating physician Diagnosed with diabetes or renal disease or received a kidney transplant within the last 36 months Service provided by a registered dietitian or nutrition professional First year: 3 hours of one-on-one counseling Subsequent years: 2 hours

28 Page 28 of 38 You cannot bill DSMT and MNT on the same date of service for the same beneficiary CPT only copyright 2018 American Medical Association. All rights reserved. Pneumococcal Vaccine and Administration Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use G0009 Administration of pneumococcal vaccine Z23 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. All Medicare beneficiaries An initial pneumococcal vaccine to Medicare beneficiaries who never received the vaccine under Medicare Part B A different, second pneumococcal vaccine 1 year after the first vaccine was administered

29 Page 29 of 38 Effective for dates of service on or after October 1, 2016, Medicare hospice providers may bill for vaccine services on institutional claims ( Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9052.pdf) Refer to Medicare Part B Immunization Billing ( Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS html) and Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations ( MLN/MLNMattersArticles/Downloads/MM9051.pdf) for more information CPT only copyright 2018 American Medical Association. All rights reserved. Prostate Cancer Screening G0102 Prostate cancer screening; digital rectal examination G0103 Prostate cancer screening; prostate specific antigen test (PSA) Z12.5 Additional ICD-10 codes may apply. See the ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. All male Medicare beneficiaries aged 50 and older (coverage begins the day after 50th birthday)

30 Page 30 of 38 Annually G0102: Copayment/coinsurance applies Deductible applies G0103: Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests G0476 Infectious agent detection by nucleic acid (dna or rna); human papillomavirus (hpv), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test Z11.51 and eitherz orz Additional ICD-10 codes may apply. See the CMS ICD-10 web ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. All asymptomatic female Medicare beneficiaries aged 30 to 65 years Once every 5 years

31 Page 31 of 38 Refer to Screening for Cervical Cancer with Human Papillomavirus (HPV) Testing ( MLN/MLNMattersArticles/Downloads/MM9434.pdf) for more information Screening for Sexually Transmitted Infections (STIs) and Chlamydia Antibody; Chlamydia Antibody; Chlamydia, IgM Culture, chlamydia, any source Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiplestep method; Chlamydia trachomatis Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique Gonorrhea Use when performing combined chlamydia and gonorrhea testing Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique 87591

32 Page 32 of 38 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique Syphilis Use when performing combined chlamydia and gonorrhea testing Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) Syphilis test, non-treponemal antibody, quantitative Antibody; Treponema pallidum Hepatitis B (Hepatitis B Surface Antigen) Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiplestep method; hepatitis B surface antigen (HBsAg) Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiplestep method; hepatitis B surface antigen (HBsAg) neutralization HIBC G0445 High intensity behavioral counseling to prevent sexually transmitted infection; face-toface, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes Z11.3, Z11.59, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z72.51, Z72.52, Z72.53, Z72.89, O09.90, O09.91, O09.92, and O09.93 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. Certain Medicare beneficiaries when all of the following are true:

33 Page 33 of 38 Sexually active adolescents and adults at increased risk for STIs Referred for this service by a primary care provider and provided by a Medicare-eligible primary care provider in a primary care setting One annual occurrence of screening for chlamydia, gonorrhea, and syphilis in women at increased risk who are not pregnant One annual occurrence of screening for syphilis in men at increased risk Up to two occurrences per pregnancy of screening for chlamydia and gonorrhea in pregnant women who are at increased risk for STIs and continued increased risk for the second screening One occurrence per pregnancy of screening for syphilis in pregnant women: Up to two additional occurrences in the third trimester and at delivery if at continued increased risk for STIs One occurrence per pregnancy of screening for hepatitis B in pregnant women: One additional occurrence at delivery if at continued increased risk for STIs Up to two 30-minute, face-to-face HIBC sessions annually For more information about increased risk for STIs and covered Medicare beneficiaries, refer to the Medicare National Coverage Determinations Manual, Chapter 1, Part 4 ( Section CPT only copyright 2018 American Medical Association. All rights reserved. Screening Mammography Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)

34 Page 34 of 38 Use as an add-on code to G0202 when tomosynthesis is used in addition to 2-D mammography Screening mammography, bilateral (2-view study of each breast), including computeraided detection (CAD) when performed Z12.31 Additional ICD-10 codes may apply. See the CMS ICD-10 webpage ( for individual CRs and coding translations for ICD-10, and contact your MAC ( Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review- Contractor-Directory-Interactive-Map/) for guidance. All female Medicare beneficiaries aged 35 and older Aged 35 through 39: One baseline Aged 40 and older: Annually If billing a screening mammogram and a diagnostic mammogram on the same day, use modifier GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) to show a screening mammography turned into a diagnostic mammography CPT only copyright 2018 American Medical Association. All rights reserved. Screening Pap Tests