Table Of Content

SERVIC^^ The Guide to Medicare n rrevent:.ive SeiVices '"'"*" rtn*"'"' ^"//•"m, «rf OrAr H,M Care Pn,fis!lonab of f PUBS RA 412 3 G855 2005 May medici Lean net c^TBts/bf/usuKA/ifa*aacAX)salvias . r The Guide to Medicare Preventive Services for Ph^ ^.^.^....^ ^ .^ ^..^.^ . Suppliers, and Other Health Care Professionals f^^ hey DISCLAIMER This Guide was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) 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 guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. ICD-9 Notice The International Classification of Diseases, 9" Revision, Clinical Modification (ICD-9-CM) is published by the United States Government. A CD-ROM, which may be purchased through the Government Printing Office, is the only official Federal government version of the ICD-9-CM. The International Classification of Diseases, 9' Revision, published by the World Health Organization (WHO) is the foundation of the ICD-9-CM. The ICD-9-CM is completely comparable with the ICD- 9. ICD-9 is published by the World Health Organization (WHO). Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the WHO Universal Copyright Convention. For rights of reproduction or translation of publications, in part or in total, application should be made to the Office of Publications, World Health Organization, Geneva, Switzerland. The World Health Organization welcomes such applications. American Medical Association (AMA) Notice and Discla CPT® codes, descriptions, and other data only are copyright 2004 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The Medicare Learning Network (MLN) The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare providers. For additional information visit the Medicare Learning Network's Medlearn web page at www.cms.hhs.gov/medlearn on the CMS website. Medicare Expands Preventive Benefits for Seniors Every year, hundreds of thousands ofAmericans die prematurely from diseases that are preventable through immunization or amendable through early detection, treatment, and lifestyle changes. The good news is that every year the statistics improve. Some of this improvement can be contributed to an increased national focus on early detection and promotion of prevention and screening sen/ices. Prior to the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the Medicare Program provided coverage for many preventive services, including: annual mammography screening, increased access to Pap tests and pelvic exams, colorectal and prostate cancer screening, glaucoma screening, diabetes supplies, diabetes self-management training, medical nutrition therapy, MMA and bone mass measurement. The further expanded preventive services for Medicare beneficiaries to include an Initial Preventive Physical Examination (IPPE), i.e., the "Welcome to Medicare" physical exam, coverage for cardiovascular screening blood tests, and coverage for diabetes screening tests. The inclusion of these new benefits continues the Centers for Medicare & Medicaid Services' (CMS') effort to move Medicare toward a prevention-oriented program. This national focus on prevention and early detection has resulted in a higher level of consumer interest in preventive medicine and a greater need for information on Medicare coverage of these preventive services. CMS is taking significant steps to reach out and educate both the provider community and beneficiaries about the array of preventive services and screenings Medicare covers for eligible beneficiaries. "The Guide to Medicare Preventive Services for Ptiysicians, Providers, Suppliers, and Ottier l-iealtti Care Professionals" is one resource that CMS has prepared for the provider community as part of a comprehensive program to promote awareness and increase utilization of these benefits. This guide also provides coverage, coding, billing, and payment information to help you file claims effectively. Complementary resources on Medicare prevention related benefits, such as web-based training courses, brochures, and other educational products for providers can be found on the Medicare Learning Network's Medlearn web page at www.cms.hhs.gov/medlearn on the CMS website. CMS recognizes the crucial role that health care providers play in promoting, providing, and educating We Medicare patients about these beneficial preventive services and screenings. need your help to convey the message that prevention, early detection, disease management, and lifestyle changes can help improve the quality of life for Medicare beneficiaries. The "Welcome to Medicare" physical exam presents a new opportunity for you to share with your Medicare patients information about prevention and screening services for which they may be eligible, and encourages utilization of these benefits as appropriate. With your help we will be able to deliver the best possible health care to Medicare beneficiaries and continue our initiative toward a prevention-oriented program. For beneficiary-related information, you or your patients may visit www.medicare.gov and/or call 1-800-MEDICARE (1-800- 633-4227). 11 Table of Contents PREFACE Why Prevention Is Important I New Preventive Services I The Information in this Guide II INITIAL PREVENTIVE PHYSICAL EXAMINATION 1 Overview 1 New Benefit - The Initial Preventive Physical Examination 1 Components ofthe Initial Preventive Physical Examination 1 Coverage Information 3 Documentation 4 Coding and Diagnosis Information 4 Procedure Codes and Descriptors 4 Diagnosis Requirements 5 Billing Requirements 5 Billing and Coding Requirements When Submitting to Carriers 5 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 5 Types of Bills for FIs 6 Special Billing Instructions for Rural Health Clinics/Federally Qualified Health Centers (RHCs/FQHCs) ... 6 Reimbursement Information 7 General Information 7 Reimbursement of Claims by Carriers 7 Reimbursement of Claims by Fiscal Intermediaries (FIs) 8 Reasons for Claim Denial 8 Written Advance Beneficiary Notice (ABN) Requirements 9 Resource Materials 10 CARDIOVASCULAR SCREENING BLOOD TESTS 13 Overview 13 New Benefit - Cardiovascular Screening Blood Tests 13 Risk Factors 13 Coverage Information 14 Documentation 14 Coding and Diagnosis Information 15 Procedure Codes and Descriptors 15 Diagnosis Requirements 15 Billing Requirements 15 Billing and Coding Requirements When Submitting to Carriers 15 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 15 Types of Bills for FIs 16 Reimbursement Information 16 General Information 16 Reimbursement of Claims by Carriers 16 Reimbursement of Claims by Fiscal Intermediaries (FIs) 17 Reasons for Claim Denial 17 Written Advance Beneficiary Notice (ABN) Requirements 17 Resource Materials 19 DIABETES SCREENING TESTS, SUPPLIES, SELF-MANAGEMENT TRAINING, AND OTHER SERVICES 21 Overview 21 Diabetes Mellitus 21 Risk Factors 21 New Benefit - Diabetes Screening Tests 22 Coverage Information 22 Coding and Diagnosis Information 23 iii Procedure Codes and Descriptors 23 Diagnosis Requirements 23 Billing Requirements 23 Billing and Coding Requirements When Submitting to Carriers 23 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 23 Types of Bills for FIs 24 Special Billing Instructions 24 Reimbursement Information 24 Reimbursement of Claims by Carriers 24 Reimbursement of Claims by Fiscal Intermediaries (FIs) 24 Reasons for Claim Denial 25 Diabetes Supplies 25 Supplies Covered 25 Blood Glucose Monitors and Associated Accessories 25 Coverage Information 25 Coding and Diagnosis Information 26 Procedure Codes and Descriptors 26 Therapeutic Shoes 26 Coverage Information 27 Coding and Diagnosis Information 27 Procedure Codes and Descriptors 27 Insulin Pumps 28 Coverage Information 28 Coding and Diagnosis Information 29 Procedure Codes and Descriptors 29 Billing Requirements 29 Billing and Coding Requirements Specific to Durable Medical Equipment Regional Carriers (DMERCs). 29 . Reimbursement Information 29 Reasons for Claim Denial 30 Diabetes Self-Management Training (DSMT) Services 30 Coverage Information 31 Coding and Diagnosis Information 33 Procedure Codes and Descriptors 33 Billing Requirements 33 General 33 Billing and Coding Requirements When Submitting to Carriers 34 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 34 Types of Bills for FIs 34 Reimbursement Information 35 Reasons for Claim Denial 36 Medical Nutrition Therapy (MNT) 36 Coverage Information 36 Coding and Diagnosis Information 37 Procedure Codes and Descriptors 37 Diagnosis Requirements 38 Billing Requirements 38 Billing and Coding Requirements When Submitting Claims to Carriers 38 Billing and Coding Requirements When Submitting Claims to Fiscal Intermediaries (FIs) 38 Types of Bills for FIs 38 Reasons for Claim Denial 39 Other Diabetes Services 39 Written Advance Beneficiary Notice (ABN) Requirements 39 Resource Materials 41 MAMMOGRAPHY SCREENING 43 Overview 43 Screening Mammography 43 Diagnostic Mammography 43 Risk Factors 44 iv Coverage Information 44 Coding and Diagnosis Information 45 Procedure Codes and Descriptors 45 Diagnosis Requirements 46 Need forAdditional Films 47 Billing Requirements 47 General Information 47 Billing and Coding Requirements When Submitting to Carriers 47 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 48 Types of Bills for FIs 48 Additional Billing Instructions for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) 49 Reimbursement Information 50 General Information 50 Reimbursement of Claims by Carriers 50 Payment Requirements for Non-Participating Physicians 50 Reimbursement of Claims by Fiscal Intermediaries (FIs) 50 Critical Access Hospital (CAH) Payment 50 CAH Payment under the Optional Method (Ali-lnclusive) 51 CAH Payment under the Standard Method 51 Skilled Nursing Facility (SNF) Payment 51 Reasons for Claim Denial 52 Written Advance Beneficiary Notice (ABN) Requirements 52 Resource Materials 53 SCREENING PAP TESTS 55 Overview 55 Risk Factors 55 Coverage Information 56 Coding and Diagnosis Information 56 Procedure Codes and Descriptors 56 Diagnosis Requirements 58 Billing Requirements 58 Billing and Coding Requirements When Submitting to Carriers 58 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 58 Types of Bills for FIs 58 Additional Billing Instructions for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) 59 Billing Requirements for the Technical Component for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) 60 Billing Requirements for the Professional Component for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) 60 Reimbursement Information 60 General Information 61 Reimbursement of Claims by Carriers 61 Reimbursement of Claims by Fiscal Intermediaries (FIs) 61 Reasons for Claim Denial 61 Written Advance Beneficiary Notice (ABN) Requirements 62 Resource Materials 63 PELVIC SCREENING EXAMINATION 65 Overview 65 Risk Factors 65 Coverage Information 65 Coding and Diagnosis Information 67 Diagnosis Requirements 67 Billing Requirements 68 Billing and Coding Requirements When Submitting to Carriers 68 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 68 Types of Bills for FIs 68 Billing Requirements for the Technical Component for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) 69 , Billing Requirements for the Professional Component for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) 69 Reimbursement Information 69 General Information 69 Reimbursement of Claims by Carriers 69 Reimbursement of Claims by Fiscal Intermediaries (FIs) 70 Reasons for Claim Denial 70 Written Advance Beneficiary Notice (ABN) Requirements 70 Resource Materials 72 COLORECTAL CANCER SCREENING 75 Overview 75 Risk Factors 76 Coverage Information 76 Screening Fecal Occult Blood Test 77 Screening Flexible Sigmoidoscopy 77 Screening Colonoscopy 77 Screening Barium Enema 78 Coding and Diagnosis Information 78 Procedure Codes and Descriptors 78 Non-Covered Colorectal Cancer Screening Services 79 Diagnosis Requirements 79 Billing Requirements 80 Billing and Coding Requirements When Submitting to Carriers 80 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 80 Types of Bills for FIs 81 Special Billing Instructions for Hospital Inpatients 82 Special Billing Instructions for Skilled Nursing Facilities (SNFs) 82 Reimbursement Information 82 Reimbursement of Claims by Carriers 82 Payment by Carriers of Interrupted and Completed Colonoscopies 82 Reimbursement of Claims by Fiscal Intermediaries (FIs) 83 Payment by FIs of Interrupted and Completed Colonoscopies 84 Critical Access Hospital (CAH) Payment by Fiscal Intermediary (Fl) of Interrupted and Completed Colonoscopies 85 Reasons for Claim Denial 85 Written Advance Beneficiary Notice (ABN) Requirements 85 Resource Materials 87 PROSTATE CANCER SCREENING 89 Overview 89 The Prostate SpecificAntigen (PSA) Blood Test 89 The Digital Rectal Examination (DRE) 90 Risk Factors 90 Coverage Information 90 The Prostate Specific Antigen (PSA) Blood Test 90 The Digital Rectal Examination (DRE) 90 Coding and Diagnosis Information 91 Procedure Codes and Descriptors 91 Diagnosis Requirements 91 Billing Requirements 91 Billing and Coding Requirements When Submitting to Carriers 91 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 91 Types of Bills for FIs 92 vi Reimbursement Information 92 Reimbursement of Claims by Carriers 92 Reimbursement of Claims by Fiscal Intermediaries (FIs) 93 Reasons for Claim Denial 93 Written Advance Beneficiary Notice (ABN) Requirements 94 Resource Materials 95 INFLUENZA, PNEUMOCOCCAL, AND HEPATITIS B VACCINATIONS 97 Overview 97 Advisory Committee on Immunization Practices (ACIP) 97 Influenza (Flu) Vaccine 97 Risk Factors for Influenza 97 Coverage Information 98 Coding and Diagnosis Information 98 Procedure Codes and Descriptors 98 Diagnosis Requirements 99 Billing Requirements 99 General Requirements 99 Billing and Coding Requirements When Submitting to Carriers 100 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 100 Additional Coverage Guidelines for Billing for Influenza Immunizations 100 Home Health Agencies (HHAs) 100 Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) 101 Types of Bills for FIs 101 Special Billing Instructions 101 Reimbursement Information 102 General Information 102 Reimbursement of Claims by Carriers 103 Participating Providers 103 Non-participating Providers 103 Reimbursement of Claims by Fiscal Intermediaries (FIs) 104 Reasons for Claim Denial 104 Pneumococcal Polysaccharide Vaccine (PPV) 104 Risk Factors for Pneumococcal Infection 105 Coverage Information 105 Revaccination 06 1 Coding and Diagnosis Information 106 Procedure Codes and Descriptors 106 Diagnosis Requirements 07 1 Billing Requirements 107 General Requirements 107 Billing and Coding Requirements When Submitting to Carriers 108 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 108 Additional Coverage Guidelines for Billing for PPV Immunizations 108 Home Health Agencies (HHAs) 108 Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) 108 Types of Bills for FIs 109 Special Billing Information 109 Reimbursement Information 110 General Information 110 Participating Providers 111 Non-participating Providers Ill Reimbursement of Claims by Fiscal Intermediaries (FIs) Ill Reasons for Claim Denial 111 Hepatitis B Virus (HBV) Vaccine 112 Dosage Information 112 Risk Factors for Hepatitis B Infection 112 Coverage Information 112 Coding and Diagnosis Information 113 vii Procedure Codes and Descriptors 113 Diagnosis Requirements 113 Billing Requirements 113 General Requirements 113 Billing and Coding Requirements When Submitting to Carriers 114 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 114 Additional Coverage Guidelines for Billing for Hepatitis B Immunizations 114 Home Health Agencies (HHAs) .114 Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) 114 Types of Bills for FIs 115 Special Billing Information 115 Reimbursement Information 115 General Information 115 Reimbursement of Claims by Fiscal Intermediaries (FIs) 116 Reasons for Claim Denial 116 Written Advance Beneficiary Notice (ABN) Requirements 116 Mass Immunizers/Roster Billers 117 What Is a "Mass Immunizer"? 117 Enrollment Requirements 117 Roster Billing Procedures 118 HIPAAand Electronic Mass Immunizer Roster Billing 118 General Information 118 Roster Billing and Paper Claims 118 Roster Billing PartA Claims 118 Roster Billing Part B Claims 119 Modified Form CMS-1500 119 Roster Claim Form 121 Other Covered Services 121 Jointly Sponsored Vaccination Clinics 121 Centralized Billing 121 What Is Centralized Billing? 122 To Participate in the Centralized Billing Program 122 Resource Materials 123 BONE MASS MEASUREMENTS 125 Overview 125 Methods of Bone Mass Measurements 125 Standardizing Bone Density Studies 125 Risk Factors 126 Coverage Information 126 Documentation 127 Coding and Diagnosis Information 128 Procedure Codes and Descriptors 128 Diagnosis Requirements 128 Billing Requirements 129 Billing and Coding Requirements When Submitting to Carriers 129 Billing and Coding Requirements When Submitting to Fiscal Intermediaries (FIs) 129 Types of Bills for FIs 129 Reimbursement Information 130 General Information 130 Reimbursement of Claims by Carriers 130 Reimbursement of Claims by Fiscal Intermediaries (FIs) 130 Reasons for Claim Denial 130 Written Advance Beneficiary Notice (ABN) Requirements 131 Resource Materials 132 vm