Coders Are Unstoppable!! Are You Sure You Can Bill Preventive Services? Presented by Pat Champion, CPC, CPC-I

Transcription

1 Coders Are Unstoppable!! Are You Sure You Can Bill Preventive Services? Presented by Pat Champion, CPC, CPC-I 1

2 Let s Take a Look Review Initial Preventive Physical Examination (IPPE) Understand the difference in the IPPE and the Annual Well Visit (AWV) along with the Subsequent Annual Well Visit Discuss other screening services and education for self management recognized by Medicare Review Medicare Immunizations Welcome to Medicare Exam (IPPE) Once in a lifetime exam Covered within first 12 months of obtaining Part B Height, weight and body mass index Referrals for further diagnostic testing Blood pressure Education, counseling, and health risk assessment 2

3 Welcome to Medicare Code Definition Welcome to Medicare Initial G0402 Preventive Physical Exam Electrocardiogram, routine ECG w/12 G0403 leads; screening for the initial preventative PE ; tracing only, without interpretation and G0404 report G0405 ; interpretation and report only G0403, G0404, G0405 can be billed in addition to G0402. EKG no longer a required part of IPPE. No specific diagnosis (ICD-9) is required. Co-insurance, co-pay and/or deductible waived only for G0402. Annual Wellness Visit (AWV) Once in a lifetime exam including Personalized Prevention Plan Services (PPPS) Person Covered One who is no longer within 12 months after the effective date of first Medicare Part B coverage One who has not received either an initial preventive physical exam or an AWV within the past 12 months 3

4 AWV Includes Establish individual s medical/family history Establish list of current providers and suppliers regularly involved in providing medical care Measure height, weight, BMI, BP and others as appropriate Detection of any cognitive impairment AWV cont. Review of individual s potential for depression Including current or past experiences Review functional ability and level of safety based on direct observation or screening questions/questionnaire 4

5 AWV cont. Establish a written screening schedule for the individual, such as a checklist for the next 5-10 years, as appropriate Patient s health status Screening History Age-appropriate p preventive services AWV cont. Establish list of risk factors and conditions and list of treatment options and their associated risks and benefits Furnish personalized health advice and a referral, as appropriate Health education Preventive counseling services Programs aimed at reducing identified risk factors and improving self-management 5

6 AWV cont. Community-based lifestyle interventions to reduce health risks and promote self-management and wellness Weight loss Physical activity Smoking cessation Fall prevention Nutrition AWV cont. Any other element(s) determined appropriate by the Secretary of Health and Human Services through h the National Coverage Determination (NCD) process Not subject to incident-to Who may perform? Doctor of medicine Doctor of osteopathy 6

7 AWV Performed By Nurse practitioner Physician assistant Clinical nurse specialist Health professional, which includes: Health educator Registered dietitian Nutrition professional Team of such medical professionals who are working under the direct supervision of a physician Subsequent Wellness Visit Performed 11 months after AWV & includes Update to medical/family history Measurements of weight (or waist circumference), blood pressure and routine measurements as deemed appropriate Update to list of current medical providers/suppliers 7

8 SWV Detection of any cognitive impairment Update to written screening schedule Update to list of risk factors Furnish appropriate health advice and referral as appropriate Annual & Subsequent Wellness Visit HCPCS Code G0438 G0439 Description Annual wellness visit, includes Personalized Prevention Plan of Service (PPPS), first visit Annual wellness visit, includes PPPS, subsequent visit No specific diagnosis (ICD-9) is required. Co-insurance, co-pay and/or deductible waived. When a significant, separately identifiable medically necessary E/M service in addition to the AWV, use with modifier 25; however, co-pay, deductible, coinsurance required for E/M service. 8

9 AWV Health Risk Assessment Intended to be a self-reported assessment Completed prior to or as part of AWV May include some biometrics obtained by provider Helps develop a prevention plan HRA Requirements 1. Collects self reported information about beneficiary 2. Can be administered independently by beneficiary or by health professional prior to or as part of AWV 3. Should be written in 5 th or 6 th grade literacy level and in plain language 9

10 AWV HRA cont. 4. Should be linguistically, age, gender and culturally appropriate for patient 5. Should ensure compliance with current science related to health promotion and disease prevention Take advantage of anticipated advances in new technology HRA and delivery systems reviewed no less than every 2 years AWV HRA Information Addressed Demographic Data Collected Age, gender, race, and ethnicity Self Assessment Health status, frailty, physical functioning Biometric Assessments Height, weight, body mass index (BMI), Height, weight, body mass index (BMI), systolic/diastolic blood pressure, blood lipids (HDL/LDL and total cholesterol, triglycerides), blood glucose 10

11 AWA HRA cont. Psychosocial Risks Depression/life satisfaction, stress/anger, loneliness/social isolation, pain/fatigue Behavioral Risks Tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual practices, motor vehicle safety (seat belt use), home safety AWV HRA Greater than 65 year-old Memory Cognition assessment, routine measures of vision and hearing - not part of HRA but AWV Activities of Daily Living (ADLs) Dressing, feeding, toileting, grooming, physical ambulation, including balance/risk of falls, and bathing 11

12 AWV HRA Greater than 65 year-old Instrumental Activities of Daily Living (IADLs) Shopping, food preparation, using the telephone, housekeeping, laundry, mode of transportation, responsibility for own mediations, and ability to handle finances AWV HRA cont. Interim guidance published by CDC on the development of a health risk assessment tool downloads/healthriskassessmentscd Cfinal.pdf 12

13 HRA Delivery Accommodations for individuals with physical, sensory, or cognitive limitations, low vision or blindness alternative formats such as large print or Braille or audio administration HRA Delivery cont. Available in patient s preferred language Allow access to and use of information and data by individuals with disabilities Web-based preferably via Internet so physician can communicate with Electronic Medical Record (EMR) or Personal Health Record (PHR) systems or both 13

14 HRA Delivery cont. Interactive telephonic For patients with physical disabilities, such as blindness or deafness Paper based Used where neither EMR nor Internet access available Modifiers EKG 93000, 93005, 93010, overridden with modifier 59 Medical nutrition therapy (MNT) cannot be overridden Prostate screening G0102 and reassessment and subsequent MNT G0270 cannot be overridden 14

15 Screening Services Medicare provides coverage for most types of screenings on a yearly basis While most screening services do not require prescriptions or referrals by a physician or qualified non-physician practitioner (i.e., clinical nurse specialist, nurse midwife, nurse practitioner, or physician i assistant) t) to be covered, there are a few exceptions Abdominal Aortic Aneurysm Screening G0389 One-time ultrasound screening for at risk beneficiaries as part of IPPE Risk factors Family history of abdominal aortic aneurysms Man age who has smoked more than 100 cigarettes Co-insurance, co-pay and/or deductible waived ICD-9 code: No specific diagnosis required 15

16 Bone Mass Measurement G0130, 77078, 77079, 77080, 77081, 77083, Covered if doctor determines patient is at risk Every 2 years (more often if medically necessary) Risk factors Age 50 or older Being a woman Being small and thin Have a low calcium diet Deductible and coinsurance apply One measurement every 24 months More frequently if medically necessary Cardiovascular Screening Medicare will cover these tests every five years Includes the following tests Cholesterol, serum or whole blood, total (82465) Lipoprotein, direct measurement, HDL cholesterol (63718) Triglycerides (84478) Lipid panel (80061) Diagnosis should reflect the screening nature V81.0 : Special screening for cardiovascular disease, ischemic heart disease V81.1 : Special screening for cardiovascular disease, hypertension V81.2 : Special screening for cardiovascular disease, other Co-insurance, co-pay and/or deductible waived Must be ordered by physician 16

17 Colorectal Cancer Screening Helps find precancerous growths Helps prevent or find cancer early One or more of the following tests may be covered Fecal Occult Blood Test If any below are performed as screening but become diagnostic, append modifier PT Flexible Sigmoidoscopy Colonoscopy Barium Enema Colorectal Cancer Screenings Test and Requirements Covered Once Every Beneficiary Pays Fecal Occult Blood Test G0328/82270 w/v76.51 Age 50 or older Flexible Sigmoidoscopy G0104 w/v months No deductible or copayment for this test Flexible Sigmoidoscopy 4 years or once every 10 No deductible or years after having a copayment for this test Age 50 or older screening colonoscopy Colonoscopy G0105 (high 24 months at high risk; No deductible or risk) every 10 years not at high copayment for this test. G0121 (not high risk) risk w/v76.51 No minimum age Barium Enema G months (high risk Pay 20% of the Medicare (alternative to G0104) if not high risk G0106 if high risk w/ V76.51 Age 50 or older every 24 months) when used instead of a sigmoidoscopy or colonoscopy approved amount for the doctor s services. In a hospital outpatient setting patient pays a copayment. 17

18 Diabetes Screening Tests Testing for people meeting risk factor requirements without ih pre-diabetes: 1 per year with pre-diabetes: 2 per year Risk Factors: Hypertension Previous elevated impaired fasting glucose or glucose intolerance Obesity Dyslipidemia Diabetes Screening Tests Risk Factors include two of the following Overweight Family history of diabetes Age 65 or older History of gestational diabetes mellitus, or delivery of a baby weighing greater than nine pounds Includes fasting blood glucose test Can be performed up to twice in a 12- month period Co-insurance, co-pay and/or deductible waived 18

19 Diabetes Screening Tests Glucose; quantitative, blood (except reagent strip) Glucose; post glucose dose (includes glucose) Glucose; tolerance test (GTT), three specimens (includes glucose) ICD-9 V77.1 Special screening for Diabetes Mellitus *NOTE: Claims submitted for a diabetes screening test t where the beneficiary meets the definition of pre-diabetes should report the HCPCS code with modifier TS. Covered Diabetes Services People with Diabetes can receive Self-management training Medical nutrition therapy Special eye exams Hemoglobin A1c tests Co-insurance, co-pay and/or deductible waived 19

20 Diabetes Self-Management Training (DSMT) Coverage for beneficiaries Recently diagnosed with diabetes At risk for complications Previously diagnosed but new to Medicare Diabetes Self-Management Training (DSMT) G0108 DSMT, individual session, per 30 minutes G0109 DSMT, group session, per 30 minutes ICD-9 = V77.1 Report TS (follow-up service) for diabetes screening where the beneficiary meets the definition of prediabetes Must exhibit risk for complications from diabetes, recently diagnosed, or previously diagnosed Up to 10 hours within continuous 12 months Up to 2 hours in subsequent years Co-insurance, co-pay and/or deductible apply 20

21 Covered Diabetes Supplies Blood sugar testing supplies Insulin and related supplies Insulin pumps Special foot care Therapeutic shoes Co-insurance, co-pay and/or deductible apply Medicare Coverage of Diabetes Supplies & Services (CMS Product No ) Glaucoma Screening G0117 By an optometrist or ophthalmologist G0118 Under the direct supervision of an optometrist or ophthalmologist Covered once every 12 months if at high risk Co-insurance, co-pay and/or deductible apply 21

22 HIV Screening Medicare covers HIV screening Pregnant women People at increased risk for the infection Anyone who asks for the test Covered once every 12 months Covered up to 3 times during a pregnancy Co-insurance, co-pay and/or deductible waived HCPCS codes G0432, G0433, G0435 Diagnosis V73.89 & V69.8 or V73.89 Pap Test and Pelvic Exam with Clinical Breast Exam Screening Pelvic & Breast Exam G0101 after 7 bullets of 11 are documented ICD 9 V76 2 V76 47 V76 49 V15 89 V72 31 ICD-9 = V76.2, V76.47, V76.49, V15.89, V72.31 Screening Pap Tests Q0091 Obtaining, preparing & conveyance of cervical or vaginal smear to lab ICD-9 same as above Covered for all women with Medicare Once every 24 months Once every 12 months At high risk for cervical or vaginal cancer Childbearing age and abnormal Pap test in the past 36 months 22

23 Screening Pelvic Exam G0101 Inspection & palpation of breasts for masses or lumps, tenderness, symmetry of nipple discharge Digital rectal examination including for sphincter tone, presence of hemorrhoids, and rectal masses Pelvic Exam With or Without Specimen Collection for Smears and Cultures External genitalia Urethral meatus Urethra Bladder Vagina Cervix Uterus Adnexa/parametria Anus & perineum 23

24 Screening Mammogram 77052, 77057, G0202 Covered for all women with Medicare One baseline mammogram age 35 to 39 Once a year starting at age 40 ICD-9 = V76.11 or V76.12 Co-insurance, co-pay and/or deductible waived Diagnostic Mammogram Used when there are clinical findings On physical exam Abnormal screening mammogram Medicare covers as many as needed Also covered for men Different payment rates if diagnostic mammogram 24

25 Prostate Cancer Screening Covered for all men with Medicare Beginning the day after 50th birthday Tests include Digital rectal exam (DRE) G0102 w/v76.44 PSA blood test G0103 w/v76.44 Co-insurance, co-pay and/or deductible waived Smoking Cessation Services Available to those with Medicare who use tobacco (regardless of whether they have signs or symptoms of tobacco-related disease), competent and alert at time of counseling, whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner Cessation counseling Up to 8 sessions per year Inpatient or outpatient Intermediate or intensive Co-insurance, co-pay and/or deductible waived Part D can help pay for drug therapy Nicotine patches Other drugs 25

26 Smoking & Tobacco-Use Cessation Counseling / G0436: Counseling visit; intermediate, greater than 3 minutes up to 10 minutes /G0437: Counseling visit; intensive, greater than 10 minutes ICD-9 for individuals who do not have signs or symptoms of tobacco-related disease: (non-dependent tobacco use disorder) V15.82 (history of tobacco use) G Codes vs Codes Medicare will waive the deductible and coinsurance / copayment for counseling and billing with G codes on or after January 1,

27 Influenza ( Flu ) Vaccine Flu vaccine covered for all people with Medicare Once each flu season Co-insurance, co-pay and/or deductible waived HCPCS Codes for Influenza Virus Vaccine Code Q2035 Description Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for IM use (Afluria) Q when administered to individuals 3 years of age and older, for IM use (Flulaval) Q when administered to individuals 3 years of age and older, for IM use (Fluvirun) Q when administered to individuals 3 years of age and older, for IM use (Fluzone) Q when administered to individuals 3 years of age and older, for IM use (Not Otherwise Specified) G0008 Administration V04.81 Need for prophylactic vaccination and inoculation against viral diseases; influenza 27

28 CPT for Influenza Virus Vaccine Code Description Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for IM use years and older, IM use Influenza virus vaccine, split virus, when administered to children 6-35 months of age for IM use years of age and older, for IM use Influenza virus vaccine, live, for intranasal use Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for IM use Pneumococcal Vaccine Code Description Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use Pneumococcal conjugate vaccine, 13 valent, for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use G0009 Administration of pneumococcal vaccine V03.82 Need for prophylactic vaccination and inoculation against bacterial diseases; other specified vaccinations against single bacterial diseases; Streptococcus pneumoniae (pneumococcus) 28

29 Pneumococcal Vaccine cont. Medicare may cover additional vaccinations based on risk All people age 65 and older Immunocompetent adults who are at increased risk of pneumococcal disease or it complications because of chronic illness e.g., cardiovascular disease, pulmonary disease, diabetes mellitus, alcoholism, cirrhosis, or cerebrospinal fluid leaks Individuals with compromised immune systems e.g., splenic dysfunction or anatomic asplenia, Hodgkin s, lymphoma, multiple myeloma, chronic renal failure, HIV, nephrotic syndrome, sickle cell, or organ transplantation Influenza and Pneumococcal Billed the Same Day Influenza CPT Code Administration: G0008 Pneumococcal CPT Code Administration: G0009 Diagnosis code when both are billed on the same day V

30 Hepatitis B Vaccine Covered for high risk End-stage renal disease Hemophilia who received Factor VIII or IX concentrates Clients of institutions for the mentally handicapped Persons who live in the same household as a Hepatitis B Virus (HBV) carrier Illicit injectable drug users Hepatitis B Vaccine Intermediate Risk Groups Staff in institutions for the mentally handicapped Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work Co-insurance, co-pay and/or deductible waived 30

31 Hepatitis B Vaccine HCPCS Description Code Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule) for intramuscular use Hepatitis B vaccine, adult dosage, for intramuscular use Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use G0010 Administration of Hepatitis B vaccine V05.3 Need for prophylactic vaccination and inoculation against single diseases; Viral hepatitis Medical Nutrition Therapy (MNT) Coverage for diabetes or renal disease (not receiving dialysis) Up to 3 hours in first year Up to 2 hours in subsequent years 97802, 97803, Initial Episode G0270, G0271 Second Referral within first year Co-insurance, co-pay and/or deductible waived 31

32 Medicare.gov medicare.gov Preventive Services Resource Guide American Cancer Society cancer.org Medicare & You Handbook CMS (Product No ) MEDICARE ( ) (TTY ) Medline Plus nlm.nih.gov/medlineplus Local State Health Insurance Programs See the Medicare & You Handbook for a complete listing Centers for Disease Control cdc.gov Flu Information flu.gov HHS Tobacco Cessation Resources surgeongeneral.gov/tobacco National Cancer Institute cancer.gov CANCER (TTY ) ACS-2345 ( ) American Diabetes Association diabetes.org DIABETES ( ) Medicare Coverage of Diabetes Supplies & Services (CMS Medicare Preventive Services To Help Keep You Healthy (CMS Product No ) Your Medicare Benefits (CMS Product No ) Quick Reference to Medicare Services Advanced Beneficiary Notice Booklet 32

33 Medicare Resources Medicare Preventive Services Manual Medicare Immunizations Medicare AWV Medicare Resources Smoking Cessation Medicare IPPE Quick Reference 33

34 Questions?? Thank You. Y all Come Back! pac@chcmed.net 34