Medicare Preventive Services Presented by Cahaba Government Benefit Administrators, LLC Provider Outreach & Education March 24, 2010
Disclaimer This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited.
Preventive Services Initial Preventive Physical Exam Abdominal Aortic Aneurysm Screening Cardiovascular Screening Diabetes Screening Diabetes Self Management Training Medical Nutrition Therapy Screening Pap Tests and Pelvic Examinations Screening Mammograms Bone Mass Measurements Colorectal Cancer Screening Prostate Cancer Screening Glaucoma Screening Immunizations Smoking Cessation Screening EKG
Initial Preventive Physical Exam (IPPE) G0402 for services January 1, 2009 and after Within first 12 months of having Part B Education, counseling and referrals No deductible January 1, 2009 and after Coinsurance applies If separate Evaluation & Management service (E&M) Modifier 25
Screening EKG EKG portion- no longer a required part of IPPE Deductible and coinsurance do apply Use the appropriate G code G0403 Full EKG Service G0404 Technical Component only G0405 Professional Component only
Abdominal Aortic Aneurysm (AAA) Screening G0389 Ultrasound exam AAA screen No deductible/coinsurance does apply Must exhibit certain risk factors Must receive referral for screening as a result of IPPE Once in a lifetime benefit
Covered services: Cardiovascular Disease Screening 80061 Lipid Panel 82465 Cholesterol 83718 Lipoprotein 84478 Triglycerides Screening diagnosis codes V81.0, V81.1, V81.2 No Deductible or coinsurance Must be ordered by Physician Covered every 5 years
Diabetes Screening 82947 Blood glucose test 82950 Post-glucose dose challenge 82951 Glucose tolerance test (GTT) No deductible or coinsurance Diagnosis code V77.1 Two screening tests/year if diagnosed with pre-diabetes One screening test/year if not diagnosed with prediabetes or never tested Not covered if already diagnosed with diabetes Referral required
Diabetes Self-Management Training (DSMT) G0108 DSMT, individual session, per 30 minutes G0109 DSMT, group session, per 30 minutes Deductible and coinsurance apply Must exhibit risk for complications from diabetes, recently diagnosed, or previously diagnosed Up to 10 hours within 12 months Up to 2 hours in subsequent years Deductible and coinsurance apply
Medical Nutrition Therapy (MNT) 97802, 97803, 97804 Initial Episode G0270, G0271 Second Referral within first year Deductible and coinsurance apply Coverage for diabetes or renal disease (not receiving dialysis) Up to 3 hours in first year Up to 2 hours in subsequent years
Bone Mass Measurements HCPCS/CPT codes G0130, 77078, 77079, 77080, 77081, 77083, 76977 Deductible and Coinsurance apply For those at risk for Osteoporosis One measurement every 24 months More frequently if medically necessary
Screening Pap Test and Screening Pelvic Exam Covered for all female Medicare beneficiaries Payment every 24 months Annually, if high risk No deductible Coinsurance does apply for Pap collection and Pelvic exam No coinsurance for Pap lab test Diagnosis codes V15.89, V72.31, V76.2, V76.47, V76.49
Screening Mammograms CPT/HCPCS codes 77052, 77057, G0202 No deductible/coinsurance does apply Eligibility determined by age Age 35-39 One Baseline screening mammography Age 40 and over Annual screening mammography Diagnosis codes V76.11 or V76.12 Modifier GG for diagnostic exam on same date
Colorectal Cancer Screening Fecal Occult Blood Test 82270, G0328 No Deductible or coinsurance applies Annual coverage For remainder; No deductible, Coinsurance applies. Flexible Sigmoidoscopy G0104 Covered every 4 years or once in 10 years after having a screening colonoscopy
Colorectal Cancer Screening Colonoscopy Every 24 months if high-risk G0105 Every 10 years if not high-risk G0121 Barium Enema Every 24 months if high-risk G0120 Every 4 years if not high-risk G0106
Prostate Cancer Screening Annually for men age 50 and over G0102 Digital Rectal Exam (DRE) Deductible and coinsurance apply G0103 Prostate Specific Antigen Test (PSA) No deductible or coinsurance apply Diagnosis V76.44
Glaucoma Screening G0117 Performed by optometrist or ophthalmologist G0118 Performed under direct supervision Deductible and coinsurance apply Covered annually if high risk Diabetes Mellitus Family History of Glaucoma African-Americans age 50 and over Hispanic-Americans age 65 and over Diagnosis V80.1
Adult Immunizations Flu vaccine (including H1N1) once per flu season Diagnosis V04.81 (for both), V06.6 (for seasonal flu only) Pneumococcal vaccine once per lifetime Diagnosis V03.82, V06.6 No deductible or coinsurance Hepatitis B Vaccine for High risk Scheduled doses Deductible and coinsurance apply Diagnosis V05.3
Immunizations Vaccine CPT/HCPCS Code(s) Influenza virus vaccine 90655, 90656, 90657, 90658, 90660 Flu administration H1N1 vaccine & administration G0008 G9141 & G9142 Pneumonia vaccine 90669, 90732 Pneumonia administration G0009 Hepatitis B vaccine 90740, 90743, 90744, 90746, 90747 Hepatitis B administration G0010
Smoking Cessation 99406 Counseling; intermediate, 3 to 10 minutes 99407 Counseling; intensive, greater than 10 minutes Deductible and coinsurance apply 2 quit attempts per year Maximum of 4 sessions per attempt Maximum of 8 sessions in 12 months
Kidney Disease Education Change Request (CR) 6557 Effective January 1, 2010 Stage IV Chronic Kidney Disease (CKD) Diagnosis 585.4 6 sessions/lifetime coverage Deductible and coinsurance apply G0420: Educational service; individual, per one hour G0421: Educational service; group, per one hour
HIV Screening Effective December 8, 2009 Pub. 100-03, Sections 190.14 and 210.7 High-risk and/or pregnant female beneficiaries Once annually if high-risk Three screenings while pregnant NEW HCPCS G0432, G0433, G0435 Diagnosis V73.89 & V69.8 or V73.89
Preventive Services Resources
Preventive Services Resources
Preventive Services Resources Pub. 100-04 Medicare Claims Processing Manual: Chapter 18 Preventive and Screening Services www.cms.hhs.gov/manuals/downloads/clm104c18.pdf Pub. 100-03, Medicare National Coverage Determinations Manual Sections 190.14 and 210.7, HIV Testing www.cms.hhs.gov/manuals/iom/ Change Request 6557 Kidney Disease Education and Change Request 6786 Screening for HIV Infection www.cms.hhs.gov/transmittals/01_overview.asp Preventive Services Educational Products www.cms.hhs.gov/mlnproducts/35_preventiveservices.asp
Preventive Services Resources Medicare Preventive Services www.cms.hhs.gov/prevntiongeninfo/ Medical Nutrition Therapy Benefit www.cms.hhs.gov/medicalnutritiontherapy CMS Home Page www.cms.hhs.gov
MEDICARE UPDATES
Contractor Updates Zone Program Integrity Contractor (ZPIC) CMS awards contract to AdvanceMed Will handle Medicare fraud and abuse complaints Medicare Contractor Provider Satisfaction Survey (MCPSS) Letters mailed to participants in January 2010 Comprehensive Error Rate Testing (CERT) November 2009 CERT Error 7.8% for all fee-for-service providers Recovery Audit Contractor (RAC) CMS approved audit issues posted on Connolly Healthcare website at www.connollyhealthcare.com/rac/pages/approved_issues.aspx
PECOS Update PECOS unavailable due to scheduled maintenance Use Internet-based PECOS prior to March 29,2010 or after April 5, 2010
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Preventive Services Any Questions?
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