Are You Sure You Can Bill Preventive Services? Disclaimer

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1 Are You Sure You Can Bill Preventive Services? AAPC Regional Conference Chicago, Illinoisi October Disclaimer The information in this presentation was current at the time the presentation was complied and does not include specific payer policies or contract language. Always consult CPT, CMS, and your payers for specific guidance in reporting services. The views expressed in this presentation are simply my interpretations of information I have read, compiled and studied. Much of the information is directly from the AMA, AAPC, CMS literature and other reputable sources. 2 1

2 Objectives Define preventive services Discuss the need for/benefits of prevention Baby boomers & Medicare beneficiaries Welcome to Medicare physicals Annual wellness exams Screening services Diabetes Cardiovascular Prostate Colorectal 3 What is a Preventive Service? Preventive Care A pattern of nursing and medical care that focuses on disease prevention and health maintenance. It includes early diagnosis of disease, discovery and identification of people at risk of development of specific problems, counseling, and other necessary intervention to avert a health problem. Screening tests, health education, and immunization programs are common examples of preventive care. Medical-dictionary.thefreedictionary.com 4 2

3 Why Preventive Services? Baby Boomers Estimated at 75 million 29% of population Healthcare Costs 16% of GDP Projected to increase to 25% by 2025 Chronic conditions easeprevention.pdf 5 Know Where to Find Guidance United States Preventive Services Task Force (USPSTF) 6 3

4 Know Where to Find Guidance CMS The Guide to Medicare Preventive Services Learning-Network- MLN/MLNProducts/downloads/mps_guide_web pdf Quick Reference Information: Preventive Services ownloads/mps S_QuickReferenceChart _ 1.pdf Preventive Services Education Products Booklets, Brochures, Fact Sheets, Educational Tools, Guides, and Web-based Training 7 CMS Specific Services Initial Preventive Physical Exam Annual Wellness Visitit Ultrasound Screening for AAA Cardiovascular Screening Blood Tests Immunizations Diabetes Related Services Glaucoma Screening Screening Mammography 8 4

5 CMS Specific Services Screening Pap and Pelvic Exams Colorectal l Cancer Screening Prostate Cancer Screening HIV Screening Bone Mass Measurements Tobacco-Use Cessation Counseling Sessions 9 Pattern of Discussion Risk factors 10 5

6 IPPE Welcome to Medicare Not a routine physical Does not include lab tests 11 Seven Components of IPPE 1. Review of the beneficiary s medical and social history with attention ti to modifiable risk factors for disease detection 2. Review of the beneficiary s potential risk factors for depression and other mood disorders 3. Review of the beneficiary s functional ability and level of safety. 12 6

7 Seven Components of IPPE 4. An examination 5. End-of-life planning 6. Education, counseling, and referral based on the previous five components 7. Education, counseling, and referral for other preventive services NOTE: 1/1/09 screening EKG no longer part of IPPE 13 IPPE One-time Must be received within the first 12 months of Medicare Part B coverage Must be furnished by physician or qualified non-physician practitioner 14 7

8 IPPE (cont) G0402 Coinsurance/Copay & Deductible Waived 15 AWV Subsequent to the IPPE Provide personalized prevention plan services (PPPS) 16 8

9 AWV Update to the patient s medical/family history Measurements of patient s weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the beneficiary s medical and family history Update to the list of patient s current medical providers and suppliers Detection of any cognitive impairment Update written screening schedule 17 AWV Update list of risk factors and conditions for interventions underway or recommended Furnish appropriate personalized health advice to the patient and referral, as appropriate, to health education or preventive counseling services or programs 18 9

10 AWV G0438, G Ultrasound Screening for AAA What is AAA? Abdominal Aortic Aneurysm Risk factors Male Age 65+ History of tobacco use (100+ cigarettes) Coronary heart disease Family history of AAA Hypercholesterolemia Hypertension Cerebrovascular disease 20 10

11 Ultrasound Screening for AAA One time G0389 V15.82 Personal history of tobacco use V17.4 Family history of other cerebrovascular disease V81.2 Special screening 21 Cardiovascular Screening Blood Tests What s covered? Total Cholesterol l Test Cholesterol Test for High Density Lipoproteins Triglycerides Test Risk factors Diabetes Family history of cardiovascular disease Diets high in saturated fats, cholesterol, and salt or sodium History of previous heart disease Hypercholesterolemia Hypertension 22 11

12 Cardiovascular Screening Blood Tests Risk factors (cont) Lack of exercise Obesity Excessive alcohol use Smoking Stress 23 Cardiovascular Screening Blood Tests Patient must have been fasting for 12 hours Every 5 years if asymptomatic 80061, 82465, 83718, V81.0, V81.1, V

13 Immunizations Not all immunizations are covered services Seasonal influenza Pneumococcal Hepatitis B 25 Immunizations: Influenza Risk Factors 26 13

14 Immunizations: Pneumococcal Risk Factors 27 Immunizations: Hepatitis B Risk Factors 28 14

15 29 Diabetes-Related Services Risk factors Hypertension Dyslipidemia Obesity, or Previous identification of an elevated impaired fasting glucose or glucose tolerance test OR at least two of the following characteristics: Overweight, Family history of diabetes, Age 65 and older, or a history of gestational DM or delivery of a baby weighing greater than 9 pounds Fasting Blood Glucose Post-Glucose Challenge Test Diabetes-Related Services 30 15

16 Risk factors Glaucoma Screening Individuals id with DM Individuals with family history of glaucoma African-Americans aged 50 and older Hispanic-Americans aged 65 and older Dilated eye exam with IOP measurement Direct ophthalmoscopy exam or a slit-lamp biomicroscopic examination 31 Glaucoma Screening Coinsurance /Copayment and Part B deductible apply 32 16

17 Screening Mammography 33 Screening vs. Diagnostic Risk factors Older Personal history or family history of breast cancer Dense breast tissue or diagnosed with certain benign breast conditions White Menstruation started before age 12 or menopause after 55 Personal history of chest radiation She or her mother were given the drug diethylstilbestrol (DES) during pregnancy First baby after 30 or no children Consumes excessive amounts of alcohol Overweight or obese Screening Mammography (cont) Under 35: No 35 39: Baseline only 40 and up: Annual 34 17

18 Screening Pap Tests Risk factors Early onset of sexual activity (age 16 and younger) Multiple sexual partners (five or more in a lifetime) History of a sexually transmitted disease (HPV or HIV) Fewer than 3 negative Pap tests or no Pap taken in last 7 years DES-exposed daughters of women who took DES during pregnancy Smoking Using birth control for an extended period of time (5 or more years) 35 Screening Pap Tests Coding & Diagnosis i Information 36 18

19 Screening Pelvic Exams Risk factors Early onset of sexual activity (age 16 and younger) Multiple sexual partners (five or more in a lifetime) History of a sexually transmitted disease (HPV or HIV) Fewer than 3 negative Pap tests or no Pap taken in last 7 years DES-exposed daughters of women who took DES during pregnancy Screening Pelvic Examination Elements: A screening pelvic examination, with or without specimen collection for smears and cultures, should include at least seven of the following elements: 37 Screening Pelvic Exams Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge; Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses; External genitalia (for example, general appearance, hair distribution, or lesions); Urethral meatus (for example, size, location, lesions, or prolapse); Urethra (for example, masses, tenderness, or scarring); Bladder (for example, fullness, masses, or tenderness); Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele); Cervix (for example, general appearance, lesions, or discharge); Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support); Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity); or Anus and perineum

20 Screening Pelvic Exams 39 Colorectal Cancer Screening Risk factors A close relative (sibling, parent, or child) who has had colorectal l cancer or an adenomatous polyp; A family history of familial adenomatous polyposis; A family history of hereditary nonpolyposis colorectal cancer; A personal history of adenomatous polyps; A personal history of colorectal cancer; or A personal history of inflammatory bowel disease, including Crohn s Disease and ulcerative colitis

21 Colorectal Cancer Screening 41 Prostate Cancer Screening Risk factors Family history of prostate cancer Men aged 50 and older Diet of red meat and high fat dairy Smoking PSA DRE 42 21

22 Prostate Cancer Screening G0102 G0103 V Risk factors HIV Screening Men who have had sex with men after 1975; Men and women having unprotected sex with multiple (more than one) partners; Past or present injection drug users; Men and women who exchange sex for money or drugs or who have sex partners who do; Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users; Individuals being treated for sexually transmitted diseases; Individuals with a history of blood transfusion between 1978 and 1985; and y ; Individuals who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals not willing to disclose high-risk behaviors

23 HIV Screening G0432, G0433, G Bone Mass Measurements Risk factors Aged 50 and older, Female gender, Family history of broken bones, Personal history of broken bones, Caucasian or Asian-American ethnicity, Small bone structure, Low body weight (less than 127 pounds), Frequent smoking or drinking, and Low-calcium diet

24 Bone Mass Measurements The bone mass measurement is performed on a qualified individual The physician or qualified non-physician practitioner treating the qualified individual must provide an order for a bone mass measurement test, following an evaluation of the need for a bone mass measurement that included a determination of the medically appropriate measurement for the individual. The service must be a radiologic or radioisotopic procedure (or other procedure) that meets the following requirements: Is performed with a bone densitometer (other than dual photon absorptiometry) or a bone sonometer (e.g., ultrasound) device approved or cleared for marketing by the FDA; Is performed for the purpose of identifying bone mass, detecting bone loss, or determining bone quality; and Includes a physician s interpretation of the procedure s results. 47 Bone Mass Measurements A qualified supplier or provider must furnish such services under the appropriate level of supervision by a physician. The service must be reasonable and medically necessary to diagnose, treat, or monitor a qualified individual. The service must be performed at a frequency that conforms to the requirements below

25 Bone Mass Measurements 49 Tobacco-Use Cessation Counseling Cessation Attempt Occurs when a qualified physician i or other Medicare-recognized i d practitioner determines that a beneficiary meets the eligibility requirements and initiates treatment with a cessation counseling attempt Up to four cessation counseling sessions (one attempt = up to 4 sessions) Cessation Counseling Session Face-to-face beneficiary contact at one of two levels 3 10 minutes Greater than 10 minutes 50 25

26 Tobacco-Use Cessation Counseling Risk factors beneficiaries Who use tobacco and have been diagnosed d with a recognized tobacco-related disease or who exhibit symptoms consistent with tobacco-related disease; Who use tobacco, regardless of whether the beneficiary has signs or symptoms oftobacco-related disease; Who are competent and alert at the time that counseling is provided; and Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner 51 Tobacco-Use Cessation Counseling 52 26

27 Resources Utilized 2012 CPT Professional Edition 2012 ICD-9-CM CM 2012 HCPCS Level II CMS Website CMS Quick Reference Chart: Preventive Services CMS The Guide to Medicare Preventive Services Various LCD and Coverage Articles 53 QUESTIONS? Chandra Stephenson, CPC, CPC-H, CPC-I, CPMA, CHA, CANPC, CEMC, CFPC, CIMC, COSC 54 27