Preventative Immunization Brochure
Table Of Contents 2016 Medicare Advantage Preventative Visits Guidelines... 1 Preventative Visits... 3 Common Preventive Services s*... 5 Additional Services Provided in Conjunction with the Wellness Visit... 9 Vaccines... 10 1
Preventative Visits Guidelines 2016 Medicare Advantage At Premier Health Group, we st with providers in a shared commitment to preventative care, keeping patients well maintaining their highest quality of life. That s why we created this toolkit f serving the preventative care needs f your Medicare Advantage patients. Inside this toolkit, you ll find: A list of covered preventative visits Initial Preventative Physical Exam (IPPE) Welcome to Medicare Preventative Visit details Personalized Prevention Plan Services (PPPS) Annual Wellness Visit details A list of covered preventative services screenings, complete with cresponding HCPCS/CPT codes, the beneficiary covered, frequency of the service, member cost A list of covered vaccinations, complete with cresponding HCPCS/CPT codes, the beneficiary covered, member cost We are happy to provide these guidelines to help you streamline your reimbursement processes, so you can keep your focus on patient care, building healthier communities, one patient at a time. 2
Preventative Visits Services HCPCS/CPT Codes Who Is Covered Frequency Beneficiary Pays Annual Wellness Visit (AWV) G0438 Initial visit G0439 Subsequent visit All Medicare beneficiaries: Who are not within 12 months after the effective date of their first Medicare Part B coverage period; Who have not received an Initial Preventive Physical Examination (IPPE) AWV within the past 12 months Once in a lifetime f G0438 (first AWV) Annually f G0439 (subsequent AWV) surance Initial Preventive Physical Examination (IPPE) Welcome to Medicare Preventive Visit G0402 IPPE G0403 EKG f IPPE G0404 EKG tracing f IPPE G0405 EKG interpret & rept f IPPE 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: surance G0403, G0404, G0405: Copayment/ coinsurance applies Deductible applies Comprehensive Preventative Exams E&M Codes with Preventative Diagnosis 99381-99397 All Medicare beneficiaries One per calendar year surance 3
Initial Preventative Physical Exam (IPPE) Welcome to Medicare Preventative Visit Includes: A review of your medical social histy related to your health education counseling about preventive services Certain screenings Certain shots Referrals f other care, if needed Height, weight, blood pressure measurements A calculation of your body mass index A simple vision test A review of your potential risk f depression your level of safety An offer to talk with you about creating advance directives Personalized Prevention Plan Services (PPPS) Annual Wellness Visit Includes: A review of your medical family histy Developing updating a list of current providers prescriptions Height, weight, blood pressure, other routine measurements Detection of any cognitive impairment Personalized health advice A list of risk facts treatment options f you A screening schedule (like a checklist) f appropriate preventive services 4
Common Preventive Services s 1 You may also provide bill separately f screenings other preventive services. Please follow Medicare-covered indications coding rules when billing Medicare-covered preventive services. Premier Health Medicare Advantage plans cover the following Medicare-covered preventive services, except where otherwise noted, f a $0 co-pay. In general, screening lab wk is not covered by Medicare therefe not covered by Premier Health Medicare Advantage plans. Services HCPCS/CPT Beneficiary Who Is Covered Frequency Codes Pays Abdominal Atic Aneurysm G0389 U/S f AAA screening Medicare beneficiaries: With certain risk facts f AAA; Who receive a referral from their physician, physician assistant, nurse practitioner, clinical nurse specialist Once in a lifetime surance Bone Mass Measurements 76977 U/S 77078 CT 77080 DEXA 77081 DEXA G0130 SEXA Certain Medicare beneficiaries who fall into at least one of the following categies: Women determined by their physician qualified nonphysician practitioner (NPP) to be estrogen deficient at clinical risk f osteoposis; Individuals with vertebral abnmalities; Individuals getting ( expecting to get) glucocticoid therapy f me than 3 months; Individuals with primary hyperparathyroidism; Individuals being monited to assess response to U.S. Food Drug Administration (FDA)- approved osteoposis drug therapy Every 2 years; Me frequently if medically necessary surance 1 Table does not include covered services f Alcohol Misuse Counseling, Cardiovascular Disease (Behavial Therapy), HIV, Obesity Counseling, Sexually Transmitted Infections Counseling, Tobacco Cessation Counseling. F me infmation on the Centers f Medicare & Medicaid Services (CMS) policies that define the procedures, to determine if a service is covered by Medicare visit www.cms.gov. 5
Services HCPCS/CPT Codes Who Is Covered Frequency Beneficiary Pays Breast Cancer (mammogram) Medicare now requires an add-on code when you furnish a mammography using 3-D mammography in conjunction with a 2-D digital mammography, effective January 1, 2015. 77052 Computer-aided detection, 77057 mammography (77063- List separately in addition to code f primary procedure) All female Medicare beneficiaries aged 35 older Aged 35 through 39: One baseline; Aged 40 older: Annually surance Cardiovascular Disease Tests 80061 Lipid panel -must include the following: 82465- Cholesterol, serum, total 83718 Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) 84478 Triglycerides All Medicare beneficiaries without apparent signs symptoms of cardiovascular disease Once every 5 years surance Cervical Vaginal Cancer Pap Tests G0123- G0124, G0141, G0143- G0145, G0147-G0148, P3000-P3001, Q0091 Pelvic (includes breast examination): G0101 Pap/ Pelvic Tests All female Medicare beneficiaries Pap Tests Annually if at high risk f developing cervical vaginal cancer childbearing age with abnmal Pap test within past 3 years Every 2 years f women at nmal risk Pelvic (includes breast examination): Annually if at high risk f developing cervical vaginal cancer, childbearing age with abnmal Pap test within past 3 years; Every 2 years f women at nmal risk Pap Tests surance Pelvic (includes breast examination): surance 6
Services HCPCS/CPT Codes Who Is Covered Frequency Beneficiary Pays Colectal Cancer 00810, 81528, 82270 G0104-G0106, G0120-G0121, G0328, G0464 F colectal cancer screening using Cologuard a Multitarget Stool DNA (sdna) Test: All Medicare beneficiaries: Aged 50 to 85 years; Asymptomatic; At average risk of developing colectal cancer F screening colonoscopies, FOBTs, flexible sigmoidoscopies, barium enemas: All Medicare beneficiaries: Aged 50 older who are at nmal risk of developing colectal cancer; At high risk of developing colectal cancer **High risk f developing colectal cancer is defined in the Code of Federal Regulations (CFR) at 42 CFR 410.37(a)(3). NOTE: F coverage of screening colonoscopies, there is no age limitation. Nmal Risk: Cologuard Multitarget Stool DNA (sdna) Test: once every 3 years; FOBT: every year; flexible sigmoidoscopy: once every 4 years (unless a screening colonoscopy has been perfmed then Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months); colonoscopy: every 10 years (unless a screening flexible sigmoidoscopy has been perfmed then Medicare may cover a screening colonoscopy only after 47 months); barium enema (as an alternative to covered screening flexible sigmoidoscopy) High Risk: FOBT: every year; flexible sigmoidoscopy: once every 4 years; colonoscopy: every 2 years (unless a screening flexible sigmoidoscopy has been perfmed then Medicare may cover a screening colonoscopy only after at least 47 months); barium enema (as an alternative to covered screening flexible sigmoidoscopy colonoscopy Colectal Cancer 7
Services HCPCS/CPT Codes Who Is Covered Frequency Beneficiary Pays Depression NOTE: Not to be billed the same day with G0348 G0439 G0444 All Medicare beneficiaries Must be furnished in a primary care setting that has staffassisted depression care suppts in place to assure accurate diagnosis, effective treatment, follow-up Annually surance Diabetes * 82947 Glucose; quantitative, blood (except reagent strip) 82950 Glucose; post glucose dose (includes glucose) 82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose) Part B covers these lab tests if you have any of these risk facts: High blood pressure (hypertension) Histy of abnmal cholesterol triglyceride levels (dyslipidemia) Obesity Histy of high blood sugar (glucose) Part B also covers these tests if 2 me of these apply to you: Age 65 older Overweight Family histy of diabetes (parents, brothers, sisters) Histy of gestational diabetes (diabetes during pregnancy), delivery of a baby weighing me than 9 pounds Two screening tests per year f beneficiaries diagnosed with prediabetes; One screening per year if previously tested but not diagnosed with prediabetes if never tested surance NOTE: Beneficiaries previously diagnosed with diabetes are not eligible f this benefit Glaucoma G0117-G0118 Medicare beneficiaries who: Have diabetes mellitus; Have a family histy of glaucoma; Are African-Americans aged 50 older; Are Hispanic-Americans aged 65 older Annually f covered beneficiaries surance applies applies 8
Services HCPCS/CPT Codes Who Is Covered Frequency Beneficiary Pays Medical Nutrition Therapy Services 97802-97804, G0270-G0271 Certain Medicare beneficiaries: Who receive a referral from their treating physician; Are diagnosed with diabetes, renal disease, who have received a kidney transplant within the last 3 years; A registered dietitian nutrition professional must provide the services First year: 3 hours of oneon-one counseling; Subsequent years: 2 hours surance Additional Services Provided in Conjunction with the Wellness Visit Only the codes listed on the Wellness Visit Chart are included in the $0 co-payment f wellness visits. If you also bill other services with the visit, those services are nmally subject to a co-payment co-insurance, that co-payment co-insurance applies even if the primary reason f the visit was f a wellness exam. This includes any clinical labaty tests other diagnostic services that CMS recognizes defines as medically necessary rather than preventive. 9
Vaccines 2 Vaccines (Br Drugs) Qualifications Employee Plan Commercial Plan Medicare Plan Diphtheria/Tetanus/ Pertussis (ACE) (DTaP) DTaP + Hepatitis B + IPV (Polio) 1 month < 7 years 1 month < 7 years Rx Medical $0 Rx Medical $0 Rx Only $0 Rx Medical $0 Rx Medical $0 Rx Only $0 DTaP + Hib + IPV 1 month < 7 years Rx Medical $0 Rx Medical $0 Rx Only $0 Haemophilus B (Hib) 1 month Rx Medical $0 Rx Medical $0 Rx Only $47 Hepatitis A 1 year Rx Medical $0 Rx Medical $0 Rx Only $47 Hepatitis A, B 1 year Rx Medical $0 Rx Medical $0 Rx Only $47 Hepatitis B low risk No Restriction Rx Medical $0 Rx Medical $0 Rx Only $47 Hepatitis B intermediate high risk No Restriction Rx Medical $0 Rx Medical $0 Rx Medical $0 Hib + Hepatitis B 1 month Rx Medical $0 Rx Medical $0 Rx Only $47 Human Papilloma Virus (HPV) Cervarix (HPV Type 16,18) Female age 9-25 years Rx Medical $0 Rx Medical $0 Rx Only $0 Human Papilloma Virus (HPV) -Gardasil (HPV Type 6,11,16,18) Males/Females age 9-26 years Rx Medical $0 Rx Medical $0 Rx Only $47 Human Papilloma Virus (HPV)-Gardasil 9 Males/Females age 9-26 years Rx Medical $0 Rx Medical $0 Rx Only $47 Influenza (injectable) 6 months Rx Medical $0 Rx Medical $0 Rx Medical $0 Influenza (intranasal) 6 months Rx Medical $0 Rx Medical $0 Rx Medical $0 Mumps, Measles, Rubella (MMR) 6 months Rx Medical $0 Rx Medical $0 Rx Only $0 2 Member Cost is based on pharmacy claim Rx= pharmacy only, any participating pharmacy Rx Medical= any participating pharmacy, physician s office, retail clinics (Minute Clinics f example) 10
Vaccines (Br Drugs) Qualifications Employee Plan Commercial Plan Medicare Plan Mumps, Measles, Rubella, Varicella (MMRV) 1-12 years of age Rx Medical $0 Rx Medical $0 Rx Only $0 Meningococcal 2 years Rx Medical $0 Rx Medical $0 Rx Only $0 Meningococcal w/ Diptheria Pneumococcal /PPSV23-- Pneumovax Pneumococcal/PCV13 -Prevnar 13 2 months Rx Medical $0 Rx Medical $0 Rx Only $0 2 years Rx Medical $0 Rx Medical $0 Rx Medical $0 1 month Rx Medical $0 Rx Medical $0 Rx Medical $0 Polio No Restriction Rx Medical $0 Rx Medical $0 Rx Only $0 Shingles (Zostavax) 50 years (MAPD) 60 year (Commercial) Rx Medical $0 Rx Medical $0 Rx Only $47 Td-tetanus-prevention 11 years Rx Medical $0 Rx Medical $0 Rx Only $47 Td-tetanus-following injury 11 years Rx Medical $0 Rx Medical $0 Rx Medical $0 Tdap-prevention 11 years Rx Medical $0 Rx Medical $0 Rx Only $47 Tdap -following injury 11 years Rx Medical $0 Rx Medical $0 Rx Medical $0 11
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