Medicare Screening & Preventive Services

1. Medicare Screening & Preventive Services Kentucky Health Department Training April 30, 2010

2. Today’s Presenters • Lindy Lady, CPC • Donna R. Morton, CPC

3. Disclaimer • National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov.

4. Objective Assist our health departments with correct billing and coding for screening and preventive services covered by Medicare.

5. Acronyms • ABN – Advance Beneficiary Notice of Non-coverage • BMI – Body Mass Index • CMS – Centers for Medicare and Medicaid Services • CPC – Certified Professional Coder • DES – Diethylstilbestrol • DSMT– Diabetes Self Management Training • HBV - Hepatitis B virus

6. Acronyms • HIV - Human immunodeficiency virus • HDL - High-density lipoproteins • MLN - Medicare Learning Network • MMR – Medicare Monthly Review • MNT – Medical Nutrition Therapy • MPFS – Medicare Physician Fee Schedule • PPV - Pneumococcal polysaccharide vaccine • SIA – Supplemental Instruction Article

7. Services Not Included in the Screening & Preventive Services Benefit

8. Services Not Part of Screening & Preventive Benefits 99385-99387, 99395-99397 Preventive Medicine Services (Not covered) S0613 Clinical Breast Exam (Not billed separately – part of G0101) 87491 Chlamydia (No LCD or NCD) 87591 Gonorrhea (No LCD or NCD) 86592 Syphilis test (L28535, A48037)

9. Services Not Part of Screening & Preventive Benefits 86701 – HIV-1 (NCD 210.7) 88142 – Cytopathology, cervical or vaginal (NCD 210.2)

10. Resource for Local and National Coverage Determinations www.NGSMedicare.com Sign in as Part B Provider Quick Links Select Medical Policy Center In addition to LCD – review Supplemental Instruction Article (SIA)

11. Screening & Preventive Services

12. Frequency Count • Begin with the month after the last covered service • Frequency of 24 months, 23 months must have passed • Frequency of 12 months, 11 months must have passed • Example – low risk patient, service paid February 2010 • Begin count March 2010 • 11 months have elapsed as of February 2011

13. Screening Pelvic Exam

14. Screening Pelvic Exam Medicare guidelines No physician order needed State law may require order Performed by doctor of medicine or osteopathy, or authorized practitioner For all female beneficiaries Includes a clinical breast exam

15. Screening Pelvic Examination Frequency High-risk female Once every 12 months Asymptomatic female Once every 24 months

16. Screening Pelvic Examination • Childbearing age and presence of cervical or vaginal cancer within past three years • Cervical/vaginal cancer risk factors • Early onset of sexual activity (under 16 years of age) • Multiple sexual partners (five or more in a lifetime) • History of a sexually-transmitted disease (including HIV infection) • Fewer than three negative or any pap smears within the previous seven years • DESexposed daughters of women who took DES during pregnancy

17. Screening Pelvic Examination Coding Exam G0101 Cervical or vaginal screening; pelvic and clinical breast examination Diagnosis Low risk patient V72.31, V76.2, V76.47, V76.49 High risk patient V15.89

18. Screening Pelvic Exam • Must include at least 7 of the elements CMS requires • Document in medical record all elements performed • Review elements on page 116 of the CMS Guide to Preventive Services • (ICN 006439)

19. Screening Pelvic Exam Reimbursement • Based on the MPFS • Medicare Part B deductible does not apply • Coinsurance does apply

20. Screening Pap Tests

21. Screening Pap Tests Medicare guidelines Physician order needed Ordered and collected by doctor of medicine or osteopathy, or authorized practitioner For all female beneficiaries

22. Screening Pap Tests Frequency High-risk female Once every 12 months Asymptomatic female Once every 24 months

23. Screening Pap Tests • Childbearing age and presence of cervical or vaginal cancer within past three years • Cervical/vaginal cancer risk factors • Early onset of sexual activity (under 16 years of age) • Multiple sexual partners (five or more in a lifetime) • History of a sexually-transmitted disease (including HIV infection) • Fewer than three negative or any pap smears within the previous seven years • DESexposed daughters of women who took DES during pregnancy

24. Screening Pap Tests • Coding • Screening pap test • G0123, G0143, G0144, G0145, G0147, G0148, P3000 • Physician’s interpretation of screening pap tests • G0124, G0141, P3001

25. Screening Pap Tests • Coding • Physician obtains, prepares, and conveys smear to laboratory • Q0091

26. Screening Pap Tests Coding Diagnosis Low-risk patient V72.31, V76.2, V76.47, V76.49 High-risk patient V15.89

27. Screening Pap Tests Reimbursement Q0091, G0124, G0141, P3001 paid under physician fee schedule Deductible does not apply Coinsurance applicable Other pap test codes paid under clinical fee schedule (100%) ABN for frequency limits

28. Smoking and Tobacco Use Cessation Counseling

29. Smoking & Tobacco Use Cessation Counseling Furnished by physician or qualified non-physician practitioner

30. Smoking & Tobacco Use Cessation Counseling Patient must meet one of these criteria: Uses tobacco and has a disease or adverse health effect linked to tobacco use Takes a therapeutic agent whose metabolism or dosing is affected by tobacco use

31. Smoking & Tobacco Use Cessation Counseling Cessation counseling session defined Face-to-face patient contact at one of two levels Intermediate (greater than 3 minutes up to 10 minutes) or Intensive (greater than 10 minutes)

32. Smoking & Tobacco Use Cessation Counseling • Cessation counseling attempt defined • Physician or NPP • Determines beneficiary meets eligibility requirements • Initiates treatment with cessation counseling attempt • Cessation counseling attempt includes • Up to four cessation counseling sessions (one attempt equals up to 4 sessions)

33. Smoking & Tobacco Use Cessation Counseling Frequency Two cessation counseling attempts every 12 months (up to 8 cessation counseling sessions)

34. Smoking & Tobacco Use Cessation Counseling Coding Counseling 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

35. Smoking & Tobacco Use Cessation Counseling Coding Diagnosis Appropriate and reflect patient eligibility for counseling

36. Smoking & Tobacco Use Cessation Counseling Payment from Medicare carrier MPFS 80% of approved Deductible and co-insurance apply http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5878.pdf

37. Diabetes Related Services

38. Diabetes • Diabetes • Fasting blood glucose 126 mg/dL or above • Two-hour post glucose challenge 200 mg/dL or above • Random glucose test over 200 mg/dL

39. Diabetes • Pre-diabetes • Fasting glucose level of 100-125 mg/dL • Two-hour post-glucose challenge of 140-199 mg/dL

40. Diabetes Screening Tests Eligibility determined by risk factors Patient must have at least one Hypertension Dyslipidemia Obesity (BMI 30 kilograms/m2 or above) Previous elevated impaired fasting glucose or glucose tolerance

41. Diabetes Screening Tests Eligibility determined by risk factors Patient must have at least two Overweight (BMI of greater than 25 but less than 30 kilograms/m2) Family history of diabetes Age 65 or older History of gestational diabetes or baby weighing more than nine pounds.

42. Diabetes Screening Tests • Physician or qualified NPP referral required • Frequency • Tested but not diagnosed pre-diabetic or never tested • One test within a 12-month period

43. Diabetes Screening Tests • Frequency • Diagnosed pre-diabetic • Two tests within 12-month period (not less than six months apart) • Deductible and coinsurance do not apply • 100% of clinical lab fee schedule

44. Diabetes Screening Tests Coding Tests 82947, 82950, 82951 Modifier TS–pre-diabetes Diagnosis V77.1 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5895.pdf

45. Diabetes Self-Management Training (DSMT) Medicare guidelines Physician or qualified NPP order required Plan of care Provided by individual associated with accredited DSMT program

46. DSMT Eligibility At risk for complications from diabetes Recently diagnosed Previously diagnosed

47. DSMT • Frequency • Initial training: 10 hours in 12 months • Follow-up training: 2 hours in subsequent years • ABN • Services denied over the limited number of hours

48. DSMT • Coding • Training • 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 • Diagnosis • No specific required • http://www.cms.hhs.gov/MLNMattersArticles/Downloads/mm5433.pdf

49. DSMT • Reimbursement • MPFS • Deductible and coinsurance apply

50. Medical Nutrition Therapy (MNT) Physician referral Provided by registered dietitian or nutrition professional enrolled with Medicare Eligibility Diabetic Renal disease