Click here to see a replay of the Laboratory Services: Preserving a Healthy Revenue Stream webinar. This webinar will help you void costly denials of payment for laboratory services by expanding your knowledge of CMS rules and guidelines for frequently ordered laboratory tests. Invite your colleagues and staff to join in this opportunity to better understand the coverage of Medicare’s Initial Preventive Physical Exam (IPPE) and Annual Wellness Visits (AWV) and enhance the documentation of medical necessity documentation submitted on test requests. Presented by laboratory expert Robin Zweifel as she will share an eye opening experience to help you preserve your bottom line.
*Note* - Replays are NOT eligible for CEU credits
Question: Is it appropriate to have an ABN signed every time a service which contains a frequency limitation is ordered? For example, can we collect a signed ABN every time for a PSA screen, in case the patient had a PSA performed at another facility during the last 11 months?
Answer: Yes. Medicare addresses the topic of issuing an ABN for frequency in the Financial Liability manual.
220.127.116.11 - Routine ABN Prohibition Exceptions (Rev. 1, 10-01-03)
ABNs may be routinely given to beneficiaries and considered to be effective notices which will protect notifiers in the following exceptional circumstances:
A. Services Which Are Always Denied for Medical Necessity - In any case where a national coverage decision provides that a particular service is never covered, under any circumstances, as not reasonable and necessary under §1862(a)(1) of the Act (e.g., at present, all acupuncture services by physicians are denied as not reasonable and necessary), an ABN that gives as the reason for expecting denial that: “Medicare never pays for this item/service” may be routinely given to beneficiaries, and no claim need be submitted to Medicare. If the beneficiary demands that a claim be submitted to Medicare, the notifier should submit the claim as a demand bill.
B. Experimental Items and Services - When any item or service which Medicare considers to be experimental (e.g., “Research Use Only” and “Investigational Use Only” laboratory tests) is to be furnished, since all such services are denied as not reasonable and necessary under §1862(a)(1) of the Act because they are not proven safe and effective, the beneficiary may be given an ABN that gives as the reason for expecting denial that: “Medicare does not pay for services which it considers to be experimental or for research use.” Alternative, more specific, language with respect to Medicare coverage for clinical trials may be substituted as necessary as the ABN’s reason for expecting denial.
C. Frequency Limited Items and Services - When any item or service is to be furnished for which Medicare has established a statutory or regulatory frequency limitation on coverage, or a frequency limitation on coverage on the basis of a national coverage decision or on the basis of the contractor’s local medical review policy (LMRP), because all or virtually all beneficiaries may be at risk of having their claims denied in those circumstances, the notifier may routinely give ABNs to beneficiaries. In any such routine ABN, the notifier must state the frequency limitation as the ABN’s reason for expecting denial (e.g., “Medicare does not pay for this item or service more often than frequency limit”).
D. Medical Equipment and Supplies Denied Because the Supplier Had No Supplier Number or the Supplier Made an Unsolicited Telephone Contact - Given that Medicare denials of payment under §1834(j)(1) of the Act on the basis of a supplier’s lack of a supplier number, and under §1834(a)(17)(B) of the Act, the prohibition on unsolicited telephone contacts, apply to all varieties of medical equipment and supplies and to all Medicare beneficiaries equally, the usual prohibition on provision of routine notices to all beneficiaries does not apply in these cases.
- Pub 100-04 Chapter 30 Section 18.104.22.168c
Question: I have seen on the AAA screening requires specific diagnosis for billing as well.
Medicare lists 3 diagnosis codes that provide coverage of the AAA ultrasound when performed as a preventive service benefit and billed with HCPCS G0389. The 3 covered diagnoses are as follows:
- V15.82 Personal history of tobacco use presenting hazards to health
- V17.4 Family history of other cardiovascular disease
- V81.2 Special screening for other and unspecified cardiovascular conditions
- G0389 Ultrasound exam AAA screen
- Pub 100-04 Chapter 18 Table of Preventive and Screening Services (Rev. 2446, Issued: 04-26-12, Effective: 07-01-12, Implementation: 10-01-12) (PDF)
- The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers and Other Health Care Professionals [PDF, 6.4MB]
- Medicare Preventive Services Quick Reference Information: Medicare Preventive Services [ICN# 006559] - 01/2009 (PDF)
Question: Should 83036 -HgbA1C be used as a diabetes screening test?
Answer: No. The CPT 83036 for billing of the Hgb A1C is not included in the Preventive Services Benefit manual. The NCD for diagnostic testing addresses Hgb A1C as follows:
"Glycated hemoglobin/protein testing is widely accepted as medically necessary for the management and control of diabetes. It is also valuable to assess hyperglycemia, a history of hyperglycemia or dangerous hypoglycemia. Glycated protein testing may be used in place of glycated hemoglobin in the management of diabetic patients, and is particularly useful in patients who have abnormalities of erythrocytes such as hemolytic anemia or hemoglobinopathies."
- NCD: Glycated Hemoglobin/Glycated Protein - 190.21 Version 1 (11/25/2002)
- 83036 Glycosylated hemoglobin test
Question: Can G0101 be billed with Q0091? If so, would a Modifier 25 be appropriate?
Question: There is an OCE edit for G0101 when billed with Q0091. OCE edit 0021
Answer: Yes. Appending modifier 25 is appropriate when billing for both the visit and the procedure.
G0101 has a visit status indicator ("V"), , modifier may be needed because it's a 'visit' code and a 'signficant' procedure.
The Correct Coding Policy Manual (Medicaid/Hospital) states:
"The HCPCS code G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) may be reported with evaluation and management (E&M) services under certain circumstances. If a Medicare covered reasonable and medically necessary E&M service requires breast and pelvic examination, HCPCS code G0101 should not be additionally reported. However, if the Medicare covered reasonable and medically necessary E&M service and the screening service, G0101, are unrelated to one another, both HCPCS code G0101 and the E&M service may be reported appending modifier 25 to the E&M service CPT code. Use of modifier 25 indicates that the E&M service is significant and separately identifiable from the screening service, G0101."
- G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination; OPPS SI=V; APC=0604
- Q0091 Obtaining screen pap smear; OPPS SI=T; APC=0191
- IOCE Specifications Manual: Attachment A - IOCE Specifications (V 13.3 10/2012) (PDF)
- National Correct Coding Initiative Policy Manual for Medicaid Services - Chapter XII: Supplemental Services HCPCS Level II Codes A0000 - V9999
Question: Does Medicare cover pregnancy?
Answer: Medicare provides certain preventive services benefits that are covered for the Medicare beneficiary that is of child bearing age and is pregnant. The pregnancy itself is not discussed here as a covered medical benefit.
Question: Please touch base on Positive result on a screening does not alter what?
Answer: When a test is ordered as a preventive screening benefit - the correct HCPCS or CPT and coding guidelines should be assigned for the screening benefit. If a test result is elevated or is positive the HCPCS or CPT is not changed to reflect a diagnostic procedure. For example, when a PAP smear is identified as requiring physician interpretation due to abnormal cells the pathologist would not report CPT 88141 for diagnostic procedure but instead would report the appropriate G-code for the screening procedure. However, subsequent testing performed may meet the requirements to be reported as indicated for diagnostic procedures.
Question: No, Screening verses diagnostic, she was too fast for me to write down the whole thought
Answer: When a patient has previously been diagnosed as at risk or with a definitive diagnosis such as hyperlipidemia the appropriate diagnosis should be provided on the request for testing and coverage will be determined based on the NCD for diagnostic testing - not under the preventive services benefit. Note that the frequency allowance for diagnostic testing differs from the 5 year time frame for preventive screening. Remember that the preventive screening benefit addresses the testing of a patient that does not present with a sign/symptom or definitive diagnosis that indicates the need for diagnostic testing. Preventive screening is intended to provide for the early detection of a disease state that is undiagnosed.
Question: RE: HIV screening - Are you saying we have to code V73.89 for primary for those patients that are getting the screening for pregnancy? Doesn't seem right, because not every pregnant patient has (other specified viral disease) The HIV screening is being done for protection of the provider, staff, and the baby. I am confused regarding this. Our SDOH request all pregnant pts are screened for HIV, and they actually just audited us for this.
Answer: Sometimes the testing performed - such as that described above is incorporated into the cost of doing business. Coverage by Medicare does not include testing that is performed based on the infection control standards of the facility.
The preventive services benefit for HIV screening is for those patients who present for voluntary testing and with a personal history indicating that they are considered at risk for development of the disease or that there is risk of exposure for the fetus. Coverage under this benefit is provided when documentation supports assignment of the required diagnoses. And, yes a claim submitted for a beneficiary who is pregnant must include both the primary and secondary diagnoses as presented.
Question: Can a subsequent AWV be provided by a different provider (not the same provider who performed the initial AWV)?
Answer: The initial exam (either the IPPE or AWV) must have occurred at least 11 full months prior to the subsequently performed AWV. There is no requirement for the beneficiary to return to the same physician or for the physician who provided the initial exam to refer the beneficiary for the subsequent physical. It is the responsibility of the provider to confirm that the frequency of the visits have meet the time increment between visits or to inform the beneficiary of the frequency limitation and issue and Advance Beneficiary Notice citing frequency as the reason for potential denial of the visit.
Question: Is the EKG screening only covered during the IPPE or could it be done during the AWV?
Answer: The EKG screening under this benefit may be performed as a result of a referral from the IPPE. The screening EKG is not a covered component of the AWV. The screening EKG will be allowed only once in a beneficiary's lifetime.
The EKG - if indicated during the AWV - would be ordered as a diagnostic procedure with the appropriate CPT reported and diagnosis code or codes that support sign/symptom/diagnosis.
Question: What are the screening documention requirements for the depression screening and cognitive impairment evaluation with the AWV examinations?
Answer: Medicare resources state that based on current or past experiences with depression or other mood disorders, the use of an appropriate screening instrument should be implemented for persons without a current diagnosis of depression. At the discretion of the provider the appropriate tool should be selected from the various standardized screening tests that are designed for this purpose and recognized by national professional medical organizations.
From NCD 210.9 v 1:
Nationally Covered Indications: Effective for claims with dates of service on or after October 14, 2011, CMS will cover annual screening up to 15 minutes for Medicare beneficiaries when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. At a minimum level, staff-assisted supports consist of clinical staff (e.g., nurse, physician assistant) in the primary care setting who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment.
Nationally Non-Covered Indications:
Screening for depression is non-covered when performed more than one time in a 12-month period. In addition, self-help materials, telephone calls, and web-based counseling are not separately reimbursable by Medicare and are not part of this NCD.
Medicare coinsurance and Part B deductible are waived for this preventive service.
- NCD: Screening for Depression in Adults - 210.9 Version 1 (10/14/2011)
- R2431CP Screening for Depression in Adults - 2012-03-23
- MM7637 Screening for Depression in Adults - 2011-11-23
- R139NCD Screening for Depression in Adults - 2011-11-23
Question: Is it appropriate to bill 99381-99397 preventive codes on the same day as the Q0094 & G0101?
Answer: There is not an NCCI code pair edit that exists for Q0091 or G0101 when billed with the E&M code series 99381-99397. Medicare resources state the following:
"The same physician may report a covered Evaluation and Management (E/M) visit and HCPCS code Q0091 for the same date of service if the E/M visit is for a separately identifiable service. In this case, modifier -25 must be reported with the E/M service and the medical records must clearly document the E/M service reported. Both procedure codes are to be shown as separate line items on the claim. These services can also be performed separately during separate office visits."
Question: Can you use a modifier if a provider orders Chol (CPT 82465) and dLDL (CPT 83721). The provder is not ordering a Lipid because the patient is not fasting and they do not want the Trig. I am no sure how to handle these.
Answer: The coverage of the direct measure LDL (CPT 83721) is a matter of medical necessity documentation for diagnostic testing. Coverage under the Preventive Services benefit does not provide payment for 83721 as this test is not intended as a screening test.
Question: You said I believe that for the ICD code to use with a screening Blood Occult test is V70.9. I have always used V76.41 (Special screening for malignant neoplasms rectum. We have never been denied using this code.
Answer: Yes, I did reference diagnosis V70.9 during the presentation when I stated that "the coverage benefit for preventive testing does not specify diagnosis coding requirements for patient's other than those of high risk for development of colorectal cancer. A general code such as V70.9 for unspecified medical examination should be appropriate.
As there is not a specified diagnosis requirement the more specific the screening diagnosis the better. Assignment of V76.41 would certainly be appropriate.