These seven components enable the Medicare provider to identify risk factors that may be associated with various diseases and to detect diseases early when outcomes are best. The provider is then able to educate and counsel the beneficiary about the identified risk factors and possible lifestyle changes that could have a positive impact on the beneficiary’s health. The IPPE includes all of the following services furnished to a beneficiary by a physician or other qualified non-physician practitioner:
Component 1 -- Review of the beneficiary’s medical and social history with attention to modifiable risk factors for disease detection
Medical history includes, at a minimum, past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments; current medications and supplements, including calcium and vitamins; and family history, including a review of medical events in the beneficiary’s family, including diseases that may be hereditary or place the individual at risk.
Social history includes, at a minimum, history of alcohol, tobacco, and illicit drug use, diet, and physical activities.
Component 2 -- Review of the beneficiary’s potential (risk factors) for depression and othermood disorders
This includes current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression. The physician or other qualified non-physician practitioner may select from various available standardized screening tests that are designed for this purpose and recognized by national professional medical organizations.
Component 3 -- Review of the beneficiary’s functional ability and level of safety
This is based on the use of appropriate screening questions or methods. The physician or other qualified
non-physician practitioner may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations. This review must include, at a minimum, the following areas:
Hearing impairment
Activities of daily living
Falls risk
Home safety
Component 4 -- A physical examination
This examination includes measurement of the beneficiary’s height, weight, and blood pressure; measurement of body mass index (required service effective January 1, 2009); a visual acuity screen; and other factors as deemed appropriate by the physician or qualified non-physician practitioner, based on the beneficiary’s medical and social history and current clinical standards.
Component 5 -- End-of-life planning
Effective for dates of service on or after January 1, 2009, the IPPE includes end-of-life planning as a required service, upon the beneficiary’s consent. End-of-life planning is verbal or written information provided to the beneficiary regarding:
The beneficiary’s ability to prepare an advance directive in the case that an injury or illness causes the beneficiary to be unable to make health care decisions, and
Whether or not the physician is willing to follow the beneficiary’s wishes as expressed in the
advance directive.
Component 6 -- Education, counseling, and referral based on the previous five components
Education, counseling, and referral, as determined appropriate by the physician or qualified non-physician practitioner, based on the results of the review and evaluation services described in the previous five components. Examples include the following:
Counseling on diet if the beneficiary is overweight
Education on prevention of chronic diseases
Referral for smoking and tobacco-use cessation counseling
Component 7 -- Education, counseling, and referral for other preventive services
Education, counseling, and referral, including a brief written plan, such as a checklist, provided to the individual for obtaining a screening EKG, if appropriate, and the appropriate screenings and other preventive services that are covered as separate Medicare Part B benefits, as listed below:
Bone mass measurements
Cardiovascular screening blood tests
Colorectal cancer screening tests
Diabetes screening tests
Diabetes outpatient self-management training services
Medical nutrition therapy for individuals with diabetes or renal disease
Pneumococcal, influenza, and hepatitis B vaccines and their administration
Prostate cancer screening tests
Screening for glaucoma
Screening mammography
Screening Pap test and screening pelvic examinations
Ultrasound screening for abdominal aortic aneurysms
Showing posts with label Medicare screening. Show all posts
Showing posts with label Medicare screening. Show all posts
Medicare coverage for Glaucoma Screening benefits. CPT G0117, G0118
Conditions of Coverage
The regulations implementing the Benefits Improvements and Protection Act of 2000, §102, provide for annual coverage for glaucoma screening for beneficiaries in the following high risk categories:
• Individuals with diabetes mellitus;
• Individuals with a family history of glaucoma; or
• African-Americans age 50 and over.
In addition, beginning with dates of service on or after January 1, 2006, 42 CFR 410.23(a)(2), revised, the definition of an eligible beneficiary in a high-risk category is expanded to include:
• Hispanic-Americans age 65 and over.
Medicare will pay for glaucoma screening examinations where they are furnished by or under the direct supervision in the office setting of an ophthalmologist or optometrist, who is legally authorized to perform the services under State law.
Screening for glaucoma is defined to include:
• A dilated eye examination with an intraocular pressure measurement; and
• A direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination.
Payment may be made for a glaucoma screening examination that is performed on an eligible beneficiary after at least 11 months have passed following the month in which the last covered glaucoma screening examination was performed.
The following HCPCS codes apply for glaucoma screening:
G0117 - Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist; and
G0118 - Glaucoma screening for high-risk patients furnished under the direct supervision of an optometrist or ophthalmologist.
The type of service for the above G codes is: TOS Q.
For providers who bill intermediaries, applicable types of bill for screening glaucoma services are 13X, 22X, 23X, 71X, 73X, 75X, and 85X. The following revenue codes should be reported when billing for screening glaucoma services:
• Comprehensive outpatient rehabilitation facilities (CORFs), critical access hospitals (CAHs), skilled nursing facilities (SNFs), independent and provider-based RHCs and free standing and provider-based FQHCs bill for this service under revenue code 770. CAHs electing the optional method of payment for outpatient services report this service under revenue codes 96X, 97X, or 98X.
• Hospital outpatient departments bill for this service under any valid/appropriate revenue code. They are not required to report revenue code 770.
The regulations implementing the Benefits Improvements and Protection Act of 2000, §102, provide for annual coverage for glaucoma screening for beneficiaries in the following high risk categories:
• Individuals with diabetes mellitus;
• Individuals with a family history of glaucoma; or
• African-Americans age 50 and over.
In addition, beginning with dates of service on or after January 1, 2006, 42 CFR 410.23(a)(2), revised, the definition of an eligible beneficiary in a high-risk category is expanded to include:
• Hispanic-Americans age 65 and over.
Medicare will pay for glaucoma screening examinations where they are furnished by or under the direct supervision in the office setting of an ophthalmologist or optometrist, who is legally authorized to perform the services under State law.
Screening for glaucoma is defined to include:
• A dilated eye examination with an intraocular pressure measurement; and
• A direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination.
Payment may be made for a glaucoma screening examination that is performed on an eligible beneficiary after at least 11 months have passed following the month in which the last covered glaucoma screening examination was performed.
The following HCPCS codes apply for glaucoma screening:
G0117 - Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist; and
G0118 - Glaucoma screening for high-risk patients furnished under the direct supervision of an optometrist or ophthalmologist.
The type of service for the above G codes is: TOS Q.
For providers who bill intermediaries, applicable types of bill for screening glaucoma services are 13X, 22X, 23X, 71X, 73X, 75X, and 85X. The following revenue codes should be reported when billing for screening glaucoma services:
• Comprehensive outpatient rehabilitation facilities (CORFs), critical access hospitals (CAHs), skilled nursing facilities (SNFs), independent and provider-based RHCs and free standing and provider-based FQHCs bill for this service under revenue code 770. CAHs electing the optional method of payment for outpatient services report this service under revenue codes 96X, 97X, or 98X.
• Hospital outpatient departments bill for this service under any valid/appropriate revenue code. They are not required to report revenue code 770.
How to calculate the frequency of Glucoma screening for coverage
Calculating the Frequency
• Once a beneficiary has received a covered glaucoma screening procedure, the beneficiary may receive another procedure after 11 full months have passed. To determine the 11-month period, start the count beginning with the month after the month in which the previous covered screening procedure was performed.
o Diagnosis Coding Requirements
• Providers bill glaucoma screening using screening (“V”) code V80.1 (Special Screening for Neurological, Eye, and Ear Diseases, Glaucoma). Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable.
o Payment Methodology
• Carriers
o Contractors pay for glaucoma screening based on the Medicare physician fee schedule. Deductible and coinsurance apply. Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge (refer to the Medicare Claims Processing Manual, Chapter 12, “Physician/Non-physician Practitioners,” for more information about the Medicare limiting charge).
Intermediaries
o Payment is made for the facility expense as follows:
• Independent and provider-based RHC/free standing and provider-based FQHC - payment is made under the all inclusive rate for the screening glaucoma service based on the visit furnished to the RHC/FQHC patient;
• CAH - payment is made on a reasonable cost basis unless the CAH has elected the optional method of payment for outpatient services in which case, procedures outlined in the Medicare Claims Processing Manual
;
• CORF - payment is made under the Medicare physician fee schedule;
• Hospital outpatient department - payment is made under outpatient prospective payment system (OPPS);
• Hospital inpatient Part B - payment is made under OPPS;
• SNF outpatient - payment is made under the Medicare physician fee schedule (MPFS); and
• SNF inpatient Part B - payment is made under MPFS.
Deductible and coinsurance apply
• Once a beneficiary has received a covered glaucoma screening procedure, the beneficiary may receive another procedure after 11 full months have passed. To determine the 11-month period, start the count beginning with the month after the month in which the previous covered screening procedure was performed.
o Diagnosis Coding Requirements
• Providers bill glaucoma screening using screening (“V”) code V80.1 (Special Screening for Neurological, Eye, and Ear Diseases, Glaucoma). Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable.
o Payment Methodology
• Carriers
o Contractors pay for glaucoma screening based on the Medicare physician fee schedule. Deductible and coinsurance apply. Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge (refer to the Medicare Claims Processing Manual, Chapter 12, “Physician/Non-physician Practitioners,” for more information about the Medicare limiting charge).
Intermediaries
o Payment is made for the facility expense as follows:
• Independent and provider-based RHC/free standing and provider-based FQHC - payment is made under the all inclusive rate for the screening glaucoma service based on the visit furnished to the RHC/FQHC patient;
• CAH - payment is made on a reasonable cost basis unless the CAH has elected the optional method of payment for outpatient services in which case, procedures outlined in the Medicare Claims Processing Manual
;
• CORF - payment is made under the Medicare physician fee schedule;
• Hospital outpatient department - payment is made under outpatient prospective payment system (OPPS);
• Hospital inpatient Part B - payment is made under OPPS;
• SNF outpatient - payment is made under the Medicare physician fee schedule (MPFS); and
• SNF inpatient Part B - payment is made under MPFS.
Deductible and coinsurance apply
Medicare benefits for Abdominal Aortic Aneurysm (AAA) Screening
Abdominal Aortic Aneurysm (AAA) Screening
Abdominal Aortic Aneurysm (AAA) is a vascular disease with life-threatening implications. If you have a family history of abdominal aortic aneurysm or have smoked at least 100 cigarettes in your lifetime, you are considered at risk.
How often is it covered?
Medicare covers this one-time screening ultrasound if you get a referral for it as a result of your "Welcome to Medicare" physical exam. You must receive the physical exam and the screening ultrasound referral (not the ultrasound exam itself) within the first twelve months you have Medicare Part B.
For whom?
People with Medicare who meet the following criteria are eligible:
He or she must get a referral for the AAA ultrasound screening from a physician or other qualified non-physician practitioner as a result of their "Welcome to Medicare" physical exam.
He or she has never had an AAA ultrasound screening paid for by Medicare.
The person with Medicare has at least one of the following risk factors a family history of abdominal aortic aneurysm is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime
Certain other risk factors may apply. Talk to your doctor to find out more.
Your costs in the Original Medicare Plan?
For the AAA screening ultrasound, you pay 20% of the Medicare-approved amount with no Part B deductible.
Abdominal Aortic Aneurysm (AAA) is a vascular disease with life-threatening implications. If you have a family history of abdominal aortic aneurysm or have smoked at least 100 cigarettes in your lifetime, you are considered at risk.
How often is it covered?
Medicare covers this one-time screening ultrasound if you get a referral for it as a result of your "Welcome to Medicare" physical exam. You must receive the physical exam and the screening ultrasound referral (not the ultrasound exam itself) within the first twelve months you have Medicare Part B.
For whom?
People with Medicare who meet the following criteria are eligible:
He or she must get a referral for the AAA ultrasound screening from a physician or other qualified non-physician practitioner as a result of their "Welcome to Medicare" physical exam.
He or she has never had an AAA ultrasound screening paid for by Medicare.
The person with Medicare has at least one of the following risk factors a family history of abdominal aortic aneurysm is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime
Certain other risk factors may apply. Talk to your doctor to find out more.
Your costs in the Original Medicare Plan?
For the AAA screening ultrasound, you pay 20% of the Medicare-approved amount with no Part B deductible.
CPT 82270, G0107 - Colorectal Cancer Screening - DX V76.41, V76.51
Procedure code and Description
82270 Colorectal cancer screening; blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided three cards or single triple card for consecutive collection)
Medicare payment policy
Background: HCPCS code G0107 (Colorectal Cancer Screening; fecal-occult blood test, 1-3 simultaneous determinations) is currently being used for Medicare billing and payment of screening FOBT. HCPCS code G0107 will be retired effective January 1, 2007. It will be replaced for Medicare billing purposes by Current Procedural Terminology (Procedure ) code 82270 (Blood, occult, by peroxidase activity (e.g., Guaiac) qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection)).
Prior to January 1, 2007, both codes were in the HCPCS data set, but Medicare only recognized HCPCS code G0107 for billing and payment of screening FOBT. Effective on or after January 1, 2007, Procedure code 82270 will be used for billing and payment purposes by Medicare for screening FOBT. Therefore, when billing for FOBT screening services for claims with dates of service December 31, 2006 and earlier, physicians, suppliers and providers should use HCPCS code G0107; when billing for FOBT screening services for claims with dates of service January 1, 2007 and later, physicians, suppliers and providers should use Procedure code 82270.
B. Policy: Effective for claims with dates of service January 1, 2007 and later, physicians, suppliers and providers shall report current Procedure code 82270 in place of HCPCS code G0107 when billing for screening FOBT.
Payment (carrier and FI) is under the MPFS except as follows:
• Fecal occult blood tests (82270* (G0107*) and G0328) are paid under the clinical diagnostic lab fee schedule except reasonable cost is paid to CAHs when submitted on TOB 85X. Deductible and coinsurance do not apply for these tests.
See section A below for payment to Maryland waiver on TOB 13X. Payment from all hospitals for non-patient laboratory specimens on TOB 14X will be based on the clinical diagnostic fee schedule, including CAHs and Maryland waiver hospitals.
• Flexible sigmoidoscopy (code G0104) is paid under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs; or current payment methodologies for hospitals not subject to OPPS.
• Colonoscopy (G0105 and G0121) and barium enemas (G0106 and G0120) are paid under OPPS for hospital outpatient departments and on a reasonable costs basis for CAHs or current payment methodologies for hospitals not subject to OPPS. Also colonoscopies may be done in an Ambulatory Surgical Center (ASC) and when done in an ASC the ASC rate applies. The ASC rate is the same for diagnostic and screening colonoscopies.
Colorectal Cancer Screening
Medicare covers one screening fecal-occult blood test for women 50 years and older once every 12 months. The attending physician must submit a written order for the test.
Beginning January 1, 2007, the guaiac based screening should be reported to Medicare using CPT code 82270 rather than HCPCS code G0107. The descriptor for CPT code 82270 reads “Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection).” Therefore the patient must complete the test by taking samples from consecutive stools.
As an alternative to the guaiac-based fecal occult blood test, (FOBT), reported with CPT-4 code 82270, Medicare also covers screening performed by immunoassay. It is reported to Medicare using HCPCS code G0328 (colorectal cancer screening; fecal occult blood test immunoassay, 1-3 simultaneous). The number of specimens required depends on the individual manufacturer’s instructions. However, Medicare will pay for only one covered FOBT per year, either 82270 or G0328, but not both.
The diagnosis code reported is either V76.41 (special screening for malignant neoplasms, rectum) or V76.51 (special screening for malignant neoplasms, colon). The patient is not responsible for any copay or deductible.
HCPCS code G0107 (Colorectal Cancer Screening; fecal-occult blood test, 1-3 simultaneous determinations) is currently being used for Medicare billing and payment of screening FOBT. HCPCS code G0107 will be retired effective January 1, 2007. It will be replaced for Medicare billing purposes by Current Procedural Terminology (CPT) code 82270 (Blood, occult, by peroxidase activity (e.g., Guaiac) qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection)). Prior to January 1, 2007, both codes were in the HCPCS data set, but Medicare only recognized HCPCS code G0107 for billing and payment of screening FOBT. Effective on or after January 1, 2007, CPT code 82270 will be used for billing and payment purposes by Medicare for screening FOBT. Therefore, when billing for FOBT screening services for claims with dates of service December 31, 2006 and earlier, physicians, suppliers and providers should use HCPCS code G0107; when billing for FOBT screening services for claims with dates of service January 1, 2007 and later, physicians, suppliers and providers should use CPT code 82270.
Billing and Coding Guidelines
• Fecal occult blood tests (82270* (G0107*) and G0328) are paid under the clinical diagnostic lab fee schedule except reasonable cost is paid to CAHs when submitted on TOB 85X. Deductible and coinsurance do not apply for these tests. See section A below for payment to Maryland waiver on TOB 13X. Payment from all hospitals for non-patient laboratory specimens on TOB 14X will be based on the clinical diagnostic fee schedule, including CAHs and Maryland waiver hospitals.
Special Payment Instructions for Non-Patient Laboratory Specimen (TOB 14X) for all hospitals Payment for colorectal cancer screenings (82270* (G0107*) and G0328) to a hospital for a non-patient laboratory specimen (TOB 14X), is the lesser of the actual charge, the fee schedule amount, or the National Limitation Amount (NLA), (including CAHs and Maryland Waiver hospitals). Part B deductible and coinsurance do not apply.
Effective for services furnished on or after January 1, 1998, the following codes are used for colorectal cancer screening services:
• CPT 82270* (HCPCS G0107*) - Colorectal cancer screening; fecal-occult blood tests, 1-3 simultaneous determinations;
• HCPCS G0104 - Colorectal cancer screening; flexible sigmoidoscopy;
• HCPCS G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;
• HCPCS G0106 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0104, screening sigmoidoscopy;
• HCPCS G0120 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0105, screening colonoscopy.
Effective for services furnished on or after July 1, 2001, the following codes are added for colorectal cancer screening services:
• HCPCS G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.
• HCPCS G0122 - Colorectal cancer screening; barium enema (noncovered).
The maximum amount Medicare will pay for a guaiac based screening FOBT (CPT code 82270) is $4.54. In some states the reimbursement is less.
Fecal Occult Blood Test
• HCPCS/CPT Code 82270 or G0328 – Covered once every 12 months – Deductible and coinsurance waived
• Provides 3 single cards, or single triple card for consecutive collection, to return for testing
• 82270- Clinical lab fee
• Dx Z12.76 or Z12.11
Screening Fecal-Occult Blood Tests (FOBT) (Codes 82270 & G0328)
Effective for services furnished on or after January 1, 1998, one screening FOBT (82270) is covered for beneficiaries who have attained age 50, at a frequency of once every 12 months. Screening FOBT means: a guaiac-based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools.
Effective for services furnished on or after January 1, 2004, payment may be made for an immunoassaybased FOBT (G0328) as an alternative to the guaiac-based FOBT (82270). Medicare will pay for only one covered FOBT per year, either 82270 or G0328, but not both. Screening FOBT, immunoassay (G0328) includes the use of a spatula to collect the appropriate number of samples or the use of a special brush for the collection of samples, as determined by the individual manufacturer’s instructions.
82270 Colorectal cancer screening; blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided three cards or single triple card for consecutive collection)
Medicare payment policy
Background: HCPCS code G0107 (Colorectal Cancer Screening; fecal-occult blood test, 1-3 simultaneous determinations) is currently being used for Medicare billing and payment of screening FOBT. HCPCS code G0107 will be retired effective January 1, 2007. It will be replaced for Medicare billing purposes by Current Procedural Terminology (Procedure ) code 82270 (Blood, occult, by peroxidase activity (e.g., Guaiac) qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection)).
Prior to January 1, 2007, both codes were in the HCPCS data set, but Medicare only recognized HCPCS code G0107 for billing and payment of screening FOBT. Effective on or after January 1, 2007, Procedure code 82270 will be used for billing and payment purposes by Medicare for screening FOBT. Therefore, when billing for FOBT screening services for claims with dates of service December 31, 2006 and earlier, physicians, suppliers and providers should use HCPCS code G0107; when billing for FOBT screening services for claims with dates of service January 1, 2007 and later, physicians, suppliers and providers should use Procedure code 82270.
B. Policy: Effective for claims with dates of service January 1, 2007 and later, physicians, suppliers and providers shall report current Procedure code 82270 in place of HCPCS code G0107 when billing for screening FOBT.
Payment (carrier and FI) is under the MPFS except as follows:
• Fecal occult blood tests (82270* (G0107*) and G0328) are paid under the clinical diagnostic lab fee schedule except reasonable cost is paid to CAHs when submitted on TOB 85X. Deductible and coinsurance do not apply for these tests.
See section A below for payment to Maryland waiver on TOB 13X. Payment from all hospitals for non-patient laboratory specimens on TOB 14X will be based on the clinical diagnostic fee schedule, including CAHs and Maryland waiver hospitals.
• Flexible sigmoidoscopy (code G0104) is paid under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs; or current payment methodologies for hospitals not subject to OPPS.
• Colonoscopy (G0105 and G0121) and barium enemas (G0106 and G0120) are paid under OPPS for hospital outpatient departments and on a reasonable costs basis for CAHs or current payment methodologies for hospitals not subject to OPPS. Also colonoscopies may be done in an Ambulatory Surgical Center (ASC) and when done in an ASC the ASC rate applies. The ASC rate is the same for diagnostic and screening colonoscopies.
Colorectal Cancer Screening
Medicare covers one screening fecal-occult blood test for women 50 years and older once every 12 months. The attending physician must submit a written order for the test.
Beginning January 1, 2007, the guaiac based screening should be reported to Medicare using CPT code 82270 rather than HCPCS code G0107. The descriptor for CPT code 82270 reads “Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection).” Therefore the patient must complete the test by taking samples from consecutive stools.
As an alternative to the guaiac-based fecal occult blood test, (FOBT), reported with CPT-4 code 82270, Medicare also covers screening performed by immunoassay. It is reported to Medicare using HCPCS code G0328 (colorectal cancer screening; fecal occult blood test immunoassay, 1-3 simultaneous). The number of specimens required depends on the individual manufacturer’s instructions. However, Medicare will pay for only one covered FOBT per year, either 82270 or G0328, but not both.
The diagnosis code reported is either V76.41 (special screening for malignant neoplasms, rectum) or V76.51 (special screening for malignant neoplasms, colon). The patient is not responsible for any copay or deductible.
HCPCS code G0107 (Colorectal Cancer Screening; fecal-occult blood test, 1-3 simultaneous determinations) is currently being used for Medicare billing and payment of screening FOBT. HCPCS code G0107 will be retired effective January 1, 2007. It will be replaced for Medicare billing purposes by Current Procedural Terminology (CPT) code 82270 (Blood, occult, by peroxidase activity (e.g., Guaiac) qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection)). Prior to January 1, 2007, both codes were in the HCPCS data set, but Medicare only recognized HCPCS code G0107 for billing and payment of screening FOBT. Effective on or after January 1, 2007, CPT code 82270 will be used for billing and payment purposes by Medicare for screening FOBT. Therefore, when billing for FOBT screening services for claims with dates of service December 31, 2006 and earlier, physicians, suppliers and providers should use HCPCS code G0107; when billing for FOBT screening services for claims with dates of service January 1, 2007 and later, physicians, suppliers and providers should use CPT code 82270.
Billing and Coding Guidelines
• Fecal occult blood tests (82270* (G0107*) and G0328) are paid under the clinical diagnostic lab fee schedule except reasonable cost is paid to CAHs when submitted on TOB 85X. Deductible and coinsurance do not apply for these tests. See section A below for payment to Maryland waiver on TOB 13X. Payment from all hospitals for non-patient laboratory specimens on TOB 14X will be based on the clinical diagnostic fee schedule, including CAHs and Maryland waiver hospitals.
Special Payment Instructions for Non-Patient Laboratory Specimen (TOB 14X) for all hospitals Payment for colorectal cancer screenings (82270* (G0107*) and G0328) to a hospital for a non-patient laboratory specimen (TOB 14X), is the lesser of the actual charge, the fee schedule amount, or the National Limitation Amount (NLA), (including CAHs and Maryland Waiver hospitals). Part B deductible and coinsurance do not apply.
• CPT 82270* (HCPCS G0107*) - Colorectal cancer screening; fecal-occult blood tests, 1-3 simultaneous determinations;
• HCPCS G0104 - Colorectal cancer screening; flexible sigmoidoscopy;
• HCPCS G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;
• HCPCS G0106 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0104, screening sigmoidoscopy;
• HCPCS G0120 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0105, screening colonoscopy.
Effective for services furnished on or after July 1, 2001, the following codes are added for colorectal cancer screening services:
• HCPCS G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.
• HCPCS G0122 - Colorectal cancer screening; barium enema (noncovered).
The maximum amount Medicare will pay for a guaiac based screening FOBT (CPT code 82270) is $4.54. In some states the reimbursement is less.
Fecal Occult Blood Test
• HCPCS/CPT Code 82270 or G0328 – Covered once every 12 months – Deductible and coinsurance waived
• Provides 3 single cards, or single triple card for consecutive collection, to return for testing
• 82270- Clinical lab fee
• Dx Z12.76 or Z12.11
Screening Fecal-Occult Blood Tests (FOBT) (Codes 82270 & G0328)
Effective for services furnished on or after January 1, 1998, one screening FOBT (82270) is covered for beneficiaries who have attained age 50, at a frequency of once every 12 months. Screening FOBT means: a guaiac-based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools.
Effective for services furnished on or after January 1, 2004, payment may be made for an immunoassaybased FOBT (G0328) as an alternative to the guaiac-based FOBT (82270). Medicare will pay for only one covered FOBT per year, either 82270 or G0328, but not both. Screening FOBT, immunoassay (G0328) includes the use of a spatula to collect the appropriate number of samples or the use of a special brush for the collection of samples, as determined by the individual manufacturer’s instructions.
Mammography Screening CPT 77057, 77055, 77056 , 77052
Procedure Code Description Site of Service
77055 Mammography; unilateral Office/Freestanding (Global) 2.52 $90.23 Facility (Professional) 1.00 $35.80 Facility (Technical) 1.52 $54.42
77056 Mammography; bilateral Office/Freestanding (Global) 3.24 $116.01 Facility (Professional) 1.24 $44.40 Facility (Technical) 2.00 $71.61
77057 Screening mammography, bilateral (2-view film study of each breast) Office/Freestanding (Global) 2.31 $82.71 Facility (Professional) 1.00 $35.80 Facility (Technical) 1.31 $46.90
Screening Mammography
Medicare covers one screening mammogram for women aged 40 years or older once every 12 months. CPT code 77057 (screening mammography, bilateral [two view film study of each breast]) is reported if a standard screening mammogram is performed. Medicare also covers computer aided detection (CAD) technology when performed in addition to the standard mammography. This service is reported using CPT add-on code +77052 (computer-aided detection (computer algorithm analysis of digital image data for lesion detection); screening mammography) in addition to code 77057. The Medicare deductible is waived for this service but the patient is responsible for 20% of the Medicare approved amount.
In April 2001, Medicare began to cover and provide additional payment for the use of digital technology for screening and diagnostic mammography studies. HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views) was developed to be reported for a screening full-field digital (FFDM) mammogram. Diagnosis code(s) V76.11 (screening mammogram for high-risk patient) or V76.12 (other screening mammogram) should be linked to the appropriate CPT-4 mammography code reported. The Medicare deductible is waived for this service but the patient is responsible for 20% of the Medicare approved amount.
A diagnostic mammogram (when the patient has an illness, disease or symptoms indicating the need for a mammogram) is covered whenever it is medically necessary.
Computer-Aided Detection (CAD) Add-On Codes
Effective for services on or after January 1, 2002 thr ugh December 31, 2003, (or April 1, 2002 for hospitals subject to OPPS) a new Procedure code 76085, CAD conversion of standard film images to digital images has been established as an add-on code that can be billed only in conjunction with the primary service screening mammography code 76092. The definition of 76085 is: “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, mammography (list separately in addition to code for primary procedure).”
NOTE: For claims with dates of service April 1, 2003 – December 31, 2003, code G0202 may be billed in conjunction with 76085.
Carriers and FIs make payment under the Medicare physician fee schedule. There is no Part B deductible. However, coinsurance is applicable.
For claims with dates of service April 1, 2005, and la er, hospitals bill for code 76082* (77051*) under the 13X bill type. The 14X bill type is no longer applicable. Appropriate TOBs for providers other than hospitals are 22X, 23X, and 85X.
Contractors must assure that claims containing code 76085 also contain HCPCS code 76092 or G0202. If not, FIs return claims to the provider with an explanation that payment for code 76085 cannot be made when billed alone. Carriers deny payment for 76085 when billed without 76092 or G0202.
NOTE: When screening CAD 76085 is billed in conjunction with a screening mammography (76092 or G0202) and the screening mammography (76092 or G0202) fails the age and frequency edits in CWF, both services will be rejected by CWF.
Effective with claims with dates of service January 1, 2004 thru December 31, 2006, HCPCS code 76083, “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with or without digitization of film radiographic images; screening mammography (list separately in addition
to code for primary procedure),” can be billed in conjunction with the primary service mammography code 76092 or G0202.
Effective with claims with dates of service January 1, 2007 and later, HCPCS code 77052, which replaces code 76083 “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with
or without digitization of film radiographic images; screening mammography (list separately in addition to code for primary procedure),” can be billed in conjunction with the primary service mammography code 77057 or G0202.
Contractors must assure that claims containing code 77052* (76083*) also contain HCPCS code 77057* (76092*) or G0202. FIs return claims containing code 77052* (76083*) that do not also contain HCPCS code 77057* (76092*) or G0202 with an explanation that payment for code 77052* (76083*) cannot be made when billed alone. Carriers deny payment for 77052* (76083*) when billed without 77057* (76092*) or G0202.
NOTE: When screening CAD 77052* (76083*) is billed in conjunction with a screening mammography (77057* (76092*) or G0202) and the screening mammography (77057* (76092*) or G0202) fails the age and frequency edits in CWF, both services will be rejected by CWF. *For claims with dates of service prior to January 1, 2007, providers report Procedure codes 76083 and 76092 or G0202. For claims with dates of service January 1, 2007 and later, providers report Procedure codes 77052 and 77057 or G0202, respectively.
Diagnostic Add-on Codes G0236 and 77051* (76082*) Effective for services on or after January 1, 2002 thru December 31, 2003, (or April 1, 2002 for hospital claims subject to OPPS), HCPCS code G0236 was established for diagnostic mammography CAD that can be billed only on the same claim with the primary service of either 76090 or 76091. The definition of G0236 is: “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation.”
The code must be listed separately in addition to code for the primary procedure.
NOTE: For claims with dates of service April 1, 2003 - December 31, 2003, code G0204 and G0206 may be billed in conjunction with G0236.
For claims with dates of service April 1, 2005, and later, hospitals bill for code 76082* (77051*) under the 13X bill type. The 14X bill type is no longer applicable. Appropriate TOBs for providers other than hospitals are 22X, 23X, and 85X.
There are no frequency limitations on film or digital diagnostic tests or CAD-diagnostic tests. Contractors must assure that claims containing code G0236 also contain HCPCS code 76090, 76091, G0204, or G0206. If not, FIs return claims to the provider with an explanation that payment for code G0236 cannot be made when billed alone. Carriers deny payment for G0236 when billed without 76090, 76091, G0204, or G0206.
Effective with claims with dates of service January 1, 2004 thru December 31, 2006, HCPCS code 76082, “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with or without digitization of film radiographic images; diagnostic mammography (list separately in ddition to code for primary procedure),” can be billed in conjunction with the primary service mammography code 76090, 76091, G0204, or G0206.
Effective Date: January 1, 2007
Implementation Date: January 2, 2007
I. GENERAL INFORMATION
A. Background: New 2007 Current Procedural Terminology (CPT) mammography codes have been assigned for screening and diagnostic mammography services. These codes will replace the current CPT codes; however the CPT code descriptors for the services are unchanged.
B. Policy: : Effective for claims with dates of service January 1, 2007 and later, providers report new CPT codes 77051, 77052, 77055, 77056, and 77057 in place of current CPT codes 76082, 76083, 76090, 76091, and 76092 respectively.
II. BUSINESS REQUIREMENTS Use “Shall" to denote a mandatory requirement Number Requirement Responsibility (place an “X” in each applicable column) SharedSystem
5327.1 Upon release of the 2007 CPT codes by the American Medical Association (AMA), contractors shall advise providers that effective for claims with dates of service January 1, 2007 and later, the following new CPT codes have been assigned to mammography services:
77051 77052 77055 77056 77057
The CPT code descriptors for the services are unchanged.
X X X 5327.2 Contractors shall advise providers to report new X X X
Number Requirement Responsibility (place an “X” in each applicable column) SharedSystem codes for mammography claims effective January 1, 2007 as follows:
• report code 77051 in place of code 76082;
•report code 77052 in place of code 76083;
• report code 77055 in place of code 76090;
• report code 77056 in place of code 76091;
• report code 77057 in place of code 76092;
5327.2.1 Contractors shall use the following type of service (TOS) for the new codes:
77051—TOS 4
77052—TOS 1
77055---TOS 4
77056---TOS 4
77057---TOS 1
X X X 5327.3 Contractors shall return to providers claims with dates of service on or after January 1, 2007, containing CPT codes 76082, 76083, 76090, 76091, or 76092. X X X X X OPPS/ OCE
5327.4 Contractors and CWF shall update their systems to discontinue CPT codes 76082, 76083, 76090, 76091, and 76092 and replace them with new CPT codes 77051, 77052, 77055, 77056, and 77057 respectively. X X X X X X
5327.5 Contractors shall update any edits in their systems that contain CPT codes 76082, 76083, 76090, 76091, 76092 to replace them with CPT codes 77051, 77052, 77055, 77056, and 77057 respectively. X X X X X X
5327.6 CWF shall apply existing frequency standards for new screening mammography CPT codes 7052 and 77057 effective January 1, 2007. X
J. Breast (Incision, Excision, Introduction, Repair and Reconstruction)
1. Since a mastectomy (CPT codes 19300-19307) describes removal of breast tissue including all lesions within the breast tissue, breast excision codes (19110-19126) generally are not separately reportable unless performed at a site unrelated to the mastectomy. However, if the breast excision procedure precedes the mastectomy for the purpose of obtaining tissue for pathologic examination which determines the need for the mastectomy, the breast excision and mastectomy codes are separately reportable.
(Modifier 58 may be utilized to indicate that the procedures were staged.) If a diagnosis was established preoperatively, an excision procedure for the purpose of obtaining additional pathologic material is not separately reportable.
Similarly, diagnostic biopsies (e.g., fine needle aspiration, core, incisional) to procure tissue for diagnostic purposes to determine whether an excision or mastectomy is necessary at the same patient encounter may be reported with modifier 58 appended to the excision or mastectomy code. However, biopsies (e.g.,Revision Date (Medicare): 1/1/2014 III-11 fine needle aspiration, core, incisional) are not separately reportable if a preoperative diagnosis exists.
2. The breast procedure codes include incision and closure. Some codes describe mastectomy procedures with ymphadenectomy and/or removal of muscle tissue. The latter procedures are not separately reportable. Except for sentinel lymph node biopsies, ipsilateral lymph node excisions are not separately reportable. Contralateral lymph node excisions may be
separately reportable with appropriate modifiers (i.e., LT, RT).
3. Sentinel lymph node biopsy is separately reportable when performed prior to a localized excision of breast or a mastectomy without lymphadenectomy. However, sentinel lymph node biopsy is not separately reportable with a mastectomy procedure that includes lymphadenectomy in the anatomic area of the sentinel lymph node biopsy. Open biopsy or excision of sentinel lymph node(s) should be reported as follows: axillary (CPT codes 38500 or 38525), deep cervical (CPT code 38510), internal mammary (CPT code 38530). (CPT code 38740(axillary lymphadenectomy; superficial) should not be reported for a sentinel lymph node biopsy. Sentinel lymph node biopsy of superficial axillary lymph node(s) is correctly reported as CPT code 38500 (biopsy or excision of lymph node(s), superficial) which includes the removal of one or more discretely identified superficial lymph nodes. By contrast a superficial axillary lymphadenectomy (CPT code 38740) requires removal of all superficial axillary adipose tissue with all lymph nodes in this adipose tissue.)
4. Breast reconstruction codes that include the insertion of a prosthetic implant should not be reported with codes that separately describe the insertion of a breast prosthesis.
5. CPT codes for breast procedures generally describe unilateral procedures.
6. If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed withmammographic guidance (e.g., 19281,19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.
Benefits for Mammography Screening - BCBS
Benefits are available for a screening by low-dose mammography for the presence of occult breast cancer for a Participant 35 years of age and older, as shown on your Schedule of Coverage, except that benefits will not be available for more than one routine mammography screening each Calendar Year.
Diagnostic Mammography
A diagnostic mammography is a radiological mammogram and is a covered diagnostic test under the following conditions:
• A patient has distinct signs and symptoms for which a mammogram is indicated;
• A patient has a history of breast cancer; or
• A patient is asymptomatic, but based on the patient’s history and other factors the
physician considers significant, the physician’s judgment is that a mammogram is appropriate.
• Beginning January 1, 2005, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, §644, Public Law 108-173 has changed the way Medicare pays for diagnostic mammography. Medicare will pay based on the MPFS in lieu of OPPS or the lower of the actual change.
Billing Requirements - A/B MAC (A) Claims
(Rev. 1519, Issued: 05-30-08, Effective: 05-23-08, Implementation: 06-30-08) A/B MACs use the weekly-updated MQSA file to verify that the billing facility is certified by the FDA to perform mammography services, and has the appropriate certification to perform the type of mammogram billed (film and/or digital). (See §20.1.) A/B MACs (A) use the provider number submitted on the claim to identify the facility and use the MQSA data file to verify the facility’s certification(s). A/B MAC (A) complete the following activities in processing mammography claims:
• If the provider number on the claim does not correspond with a certified mammography facility on the MQSA file, then A/B MACs (A) deny the claim.
• When a film mammography HCPCS code is on a claim, the claim is checked for a “1” film indicator.
• If a film mammography HCPCS code comes in on a claim and the facility is certified for film mammography, the claim is paid if all other relevant Medicare criteria are met.
• If a film mammography HCPCS code is on a claim and the facility is certified for digital mammography only, the claim is denied.
• When a digital mammography HCPCS code is on a claim, the claim is checked for “2” digital indicator.
• If a digital mammography HCPCS code is on a claim and the facility is certified for digital mammography, the claim is paid if all other relevant Medicare criteria are met.
• If a digital mammography HCPCS code is on a claim and the facility is certified for film mammography only, the claim is denied.
NOTE: The Common Working File (CWF) no longer receives the mammography file for editing purposes.
Except as provided in the following sections for RHCs and FQHCs, the following procedures apply to billing for screening mammographies:
The technical component portion of the screening mammography is billed on Form CMS- 1450 under bill type 12X, 13X, 14X**, 22X, 23X or 85X using revenue code 0403 and HCPCS code 77057* (76092*).
The technical component portion of the diagnostic mammography is billed on Form CMS-1450 under bill type 12X, 13X, 14X**, 22X, 23X or 85X using revenue code 0401 and HCPCS code 77055* (76090*), 77056* (76091*), G0204 and G0206.
Separate bills are required for claims for screening mammographies with dates of service prior to January 1, 2002. Providers include on the bill only charges for the screening mammography. Separate bills are not required for claims for screening mammographies with dates of service on or after January 1, 2002. See separate instructions below for rural health clinics (RHCs) and federally qualified health centers (FQHCs).
* For claims with dates of service prior to January 1, 2007, providers report CPT codes 76090, 76091, and 76092. For claims with dates of service January 1, 2007 and later, providers report CPT codes 77055, 77056, and 77057 respectively.** For claims with dates of service April 1, 2005 and later, hospitals bill for all mammography services under the 13X type of bill or for dates of service April 1, 2007 and later, 12X or 13X as appropriate. The 14X type of bill is no longer applicable.
Appropriate bill types for providers other than hospitals are 22X, 23X, and 85X.
In cases where screening mammography services are self-referred and as a result an attending physician NPI is not available, the provider shall duplicate their facility NPI in the attending physician identifier field on the claim.
A/B MACs (B) complete the type of service field in the CWF Part B claim record with a “B” if the patient is a high risk screening mammography patient or a “C” if she is a low risk screening mammography patient for services prior to January 1, 1998.
For services on or after January 1, 1998, the type of service field on CWF must have a value of “1” for medical care (screening) or a “4” for diagnostic radiology (diagnostic). Fill in POS. Fill in deductible indicator field with a “1”; not subject to deductible if screening mammography. Submit the claim to the CWF host. Trailer 17 of the Part B Basic Reply record will give the date of the last screening mammography. The CWF edits for age and frequency for screening mammography. There are no frequency limitations on diagnostic tests or CAD-diagnostic tests. When a screening CAD is billed in conjunction with a screening mammogram and the screening mammogram fails the age or frequency edits then both services will be rejected.
Claims With Dates of Service October 1, 1998 Through December 31, 2001
A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while the beneficiary is still at the facility for the screening exam. Where a radiologist interpretation results in additional films, the mammography is no longer considered a screening exam for application of age and frequency standards or for payment purposes. This can be done without an additional order from the treating physician. When this occurs, the claim will be billed and paid as a diagnostic mammography instead of a screening mammography. However, since the original intent for the exam was for screening, for statistical purposes, the claim is considered a screening.
The claim should be prepared for A/B MAC (A) processing reflecting the diagnostic revenue code (0401) along with HCPCS code 76090, 76091, G0204, G0206 or G0236 as appropriate and modifier “-GH” “Diagnostic mammogram converted from screening mammogram on same day.” Statistics will be collected based on the presence of modifier “-GH.” A separate claim is not required. Regular billing instructions remain in place for mammograms that do not fit this situation. A/B MACs (B) should receive a claim for a screening mammogram with CPT code 76092 (screening mammography, bilateral) (Type of Service = 1) but, if the screening
mammogram turns into a diagnostic mammogram, the claim is billed with CPT code 76090 (unilateral) or 76091 (bilateral), (TOS= 4), with the “-GH” modifier. A/B MACs (B) pay the claim as a diagnostic mammography instead of a screening mammography.
NOTE: However, the ordering of a diagnostic test by a radiologist following a screening test that shows a potential problem need not be on the same date of service.
In this case, where additional diagnostic tests are performed for the same beneficiary, same visit on the same day, the UPIN of the treating physician is needed on the A/B MACs (B) claim. The radiologist must refer back to the treating physician for his/her UPIN and also report to the treating physician the condition of the patient. A/B MACs (B) need to educate radiologists and treating physicians that the treating physician’s UPIN is required whenever a physician refers or orders a diagnostic lab or radiology service. If no UPIN is present for the diagnostic mammography code, the A/B MACs (B) will reject the claim
Claims With Dates of Service On or After January 1, 2002, (or On or After April 1, 2002 for Hospitals Subject to OPPS)
A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam. When a radiologist’s interpretation results in additional films, Medicare will pay for both the screening and diagnostic mammogram.
A/B MACs (B) Claims
For A/B MACs (B) claims, providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier “- GG” to the diagnostic mammography. A modifier “-GG” is appended to the claim for the diagnostic mammogram for tracking and data collection purposes. Medicare will reimburse both the screening mammography and the diagnostic mammography.
A/B MAC (A) Claims
A/B MACs (A) require the diagnostic claim be prepared reflecting the diagnostic revenue code (0401) along with HCPCS code 77055* (76090*), 77056* (76091*), G0204, G0206 or G0236 and modifier “-GG” “Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.” Reporting of this modifier is needed for data collection purposes. Regular billing instructions remain in place for a screening mammography that does not fit this situation. Both A/B MACs (A) and (B) systems must accept the GH and GG modifiers where appropriate.
* For claims with dates of service prior to January 1, 2007, providers report CPT codes
76090 and 76091. For claims with dates of service January 1, 2007 and later, providers report CPT codes 77055 and 77056 respectively.
Mammograms Performed With New Technologies
(Rev. 1070, Issued: 09-29-06, Effective: 01-01-07, Implementation: 01-02-07) Section 104 of the Benefits Improvement and Protection Act 2000, (BIPA) entitled Modernization of Screening Mammography Benefit, provides for new payment methodologies for both diagnostic and screening mammograms that utilize advanced new technologies for the period April 1, 2001, to December 31, 2001 (to March 31, 2002 for hospitals subject to OPPS). Under this provision, payment for technologies that directly take digital images would equal 150 percent of the amount that would otherwise be paid for a bilateral diagnostic mammography. For technologies that convert standard film images to digital form, payment will be derived from the statutory screening mammography limit plus an additional payment of $15.00 for A/B MACs (B) claims and $10.20 for A/B MAC (A) (technical component only) claims.
Payment restrictions for digital screening and diagnostic mammography apply to those facilities that meet all FDA certifications as provided under the Mammography Quality Standards Act. However, CAD codes billed in conjunction with digital mammographies or film mammographies are not subject to FDA certification requirements.
Mammography related CAD equipment does not require FDA certification.
Mammography utilizes a direct x-ray of the breast. By contrast, the CAD process uses laser beam to scan the mammography film from a film (analog) mammography, converts it into digital data for the computer, and analyzes the video display for areas suspicious for cancer. The CAD process used with digital mammography analyzes the data from the mammography on a video display for suspicious areas. The patient is not required to be present for the CAD process.
Only one screening mammogram, either 77057* (76092*) or G0202, may be billed in a calendar year. Therefore, providers/suppliers must not submit claims reflecting both a film screening mammography (77057* (76092*)) and a digital screening mammography G0202. Also, they must not submit claims reflecting HCPCS codes 77055* (76090*) or
77056* (76091*) (diagnostic mammography-film) and G0204 or G0206 (diagnostic mammography-digital). MACs deny the claim when both a film and digital screening or diagnostic mammography is reported. However, a screening and diagnostic mammography can be billed together.
* For claims with dates of service prior to January 1, 2007, providers report CPT codes 76090, 76091, and 76092. For claims with dates of service January 1, 2007 and later, providers report CPT codes 77055, 77056, and 77057 respectively.
HCPCS Definition
G0202 Screening mammography producing direct digital image, bilateral, all views
Payment Method:
Payment will be the lesser of the provider’s charge or the amount that will be provided for this code in the pricing file. (That amount is 150 percent of the locality specific technical component payment amount under the physician fee schedule for CPT code 76091, the code for bilateral diagnostic mammogram, during 2001.) Part B deductible does not apply. Coinsurance will equal 20 percent of the lesser of the actual charge or 150 percent of the locality specific payment of CPT code 76091.
HCPCS Definition
G0204 Diagnostic mammography, direct digital image, bilateral, all views
Payment Method:
Payment will be the lesser of the provider’s charge or the amount that will be provided for this code in the pricing file. (That amount is 150 percent of the locality specific amount paid under the physician fee schedule for the technical component (TC) of CPT code 76091, the code for a bilateral diagnostic mammogram.) Deductible is applicable. Coinsurance will equal 20 percent of the lesser of the actual charge or 150 percent of the locality specific payment of CPT code 76091.
NOTE: Effective January 1, 2005, payment will be made under MPFS for claims from hospitals subject to OPPS.
HCPCS Definition
G0206 Diagnostic mammography, direct digital image, unilateral, all views.
Payment Method:
Payment will be made based on the same amount that is paid to the provider, under the payment method applicable to the specific provider type (e.g., hospital, rural health clinic, etc.) for CPT code 76090, the code for a mammogram, and one breast. For example, this service, when furnished as a hospital outpatient service, will be paid the amount under the outpatient prospective payment system (OPPS) for CPT code 76090. Deductible applies. Coinsurance is the national unadjusted coinsurance for the APC wage adjusted for the specific hospital. NOTE: Effective January 1, 2005, payment will be made under MPFS for claims from hospitals subject to OPPS.
HCPCS Definition
G0207 Diagnostic mammography, film processed to produce digital image analyzed for potential abnormalities, unilateral, all views.
Payment Method:
Payment will be based on the same amount that is paid to the provider, under the payment method applicable to the specific provider type (e.g., hospital, rural health clinic, etc.) for CPT code 76090, the code for mammogram, and one breast. For example, this service, when furnished as a hospital outpatient service, will be paid the amount payable under the OPPS for CPT code 76090. Deductible applies. Coinsurance is the national unadjusted coinsurance for the APC wage adjusted for the specific hospital.
Providers bill for the technical portion of screening and diagnostic mammograms on Form CMS-1450 under bill type 13X, 22X, 23X, or 85X. The professional component is billed to the A/B MACs (B) on Form CMS-1500 (or electronic equivalent). Providers bill for digital screening mammographies on Form CMS-1450, utilizing revenue code 0403 and HCPCS G0202 or G0203. Providers bill for digital diagnostic mammographies on Form CMS-1450, utilizing revenue code 0401 and HCPCS G0204, G0205, G0206 or G0207. NOTE: Codes G0203, G0205 and G0207 are not billable codes for claims with dates of service on or after January 1, 2002.
Screening mammograms are covered annually for women 40 years of age and older. The Spanish version of this MSN message should read: El examen de mamografÃa de cernimiento se cubre una vez al año para mujeres de 40 años de edad o más. For A/B MACs (B) only: For claims submitted with invalid or missing certification number, use the following MSN: MSN 9.2:
This item or service was denied because information required to make payment was missing.
For claims submitted by a facility not certified to perform digital mammograms, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.
What is a mammagrom?
Mammography is an x-ray imaging method used to examine the breast for the early detection of cancer and other breast diseases. It is used as both a diagnostic and screening tool.
How does it work?
During a mammogram, a patient’s breast is placed on a flat support plate and compressed with a parallel plate called a paddle. An x-ray machine produces a small burst of x-rays that pass through the breast to a detector located on the opposite side. The detector can be either a photographic film plate, which captures the x-ray image on film, or a solid-state detector, which transmits electronic signals to a computer to form a digital image. The images produced are called mammograms. On a film mammogram, areas of low density, such as fatty tissue, appear translucent (i.e. similar to the black background)., whereas areas of dense tissue, such as connective and glandular tissue or tumors, appear whiter on a black background. In a standard mammogram, both a top and a side view are taken of each breast, although extra views may be taken if the physician is concerned about a particular area of the breast.
What will the results look like?
A radiologist will carefully examine a mammogram to search for areas or types of tissue that look different from normal tissue. These areas could represent many different types of abnormalities, including cancerous tumors, non-cancerous masses called benign tumors, fibroadenomas, or complex cysts. Radiologists look at the size, shape, and contrast of a mass, as well as the edges or margins, which can indicate the possibility of malignancy (i.e. cancer). They also look for tiny bits of calcium, called microcalcifications, which show up as very bright specks on a mammogram. While usually benign, microcalcifications may occasionally indicate the presence of a specific type of cancer. If a mammogram is abnormal, the radiologist may order additional mammogram views, as well as additional magnification or compression, and if suspicious areas are detected, he/she may order a biopsy.
What is digital mammography?
A digital mammogram uses the same x-ray technology as conventional mammograms, but instead of using film, solid-state detectors are used. These detectors convert the x-rays that pass through them into electronic signals that are sent to a computer. The computer then converts these electronic signals into images that can be displayed on a monitor and also stored for later use. Several advantages of using digital mammography over film mammography include: the ability to manipulate the image contrast for better clarity, the ability to use computer-aided diagnosis, and the ability to easily transmit digital files to other experts for a second opinion. In addition, digital mammograms may decrease the need for the re-takes, which are common with film mammography due to incorrect exposure techniques or problems with film development. As a result, digital mammography can lead to lower effective patient x-ray exposures.
In 2005, results from a large clinical trial sponsored by the National Cancer Institute found that digital mammography was superior to film mammography for the following populations[1]
• Women under 50
• Women with dense breasts
• Women who have not gone through menopause or who have been in menopause less than one year
What are the limits of mammography?
For certain types of breasts, mammograms can be difficult to interpret. This is because there is a wide variation in breast tissue density among women. Denser breasts are more difficult to image, and more difficult to diagnose. For this and other reasons, the sensitivity of mammography in detecting cancer can vary over a wide range. For many difficult cases, x-ray mammography alone may not be sufficiently sensitive or accurate in detecting cancer, so additional imaging technologies, such as ultrasound
What are the limits of mammography?
For certain types of breasts, mammograms can be difficult to interpret. This is because there is a wide variation in breast tissue density among women. Denser breasts are more difficult to image, and more difficult to diagnose. For this and other reasons, the sensitivity of mammography in detecting cancer can vary over a wide range. For many difficult cases, x-ray mammography alone may not be sufficiently sensitive or accurate in detecting cancer, so additional imaging technologies, such as ultrasound or magnetic resonance imaging (MRI) may also be used to increase the sensitivity of the exam. Finally, although the majority of abnormal mammograms are false-positives, when cancer is present, early detection can save lives.
Are there risks?
Because mammography uses x-rays to produce images of the breast, patients are exposed to a small amount of ionizing radiation. The risk associated with this dose appears to be greater among younger women (under age 40). However, in some cases, the benefits of using mammography to detect breast cancer under age 40 may outweigh the risks of radiation exposure. For example, a mammogram may reveal that a suspicious mass is benign and, therefore, doesn’t need to be treated. Additionally, if a tumor is malignant and is caught early by mammogram, a surgeon may be able to remove it before it spreads and requires more aggressive treatment such as chemotherapy.Different groups provide different guidelines for mammography. For instance, the American Cancer Society as well as the American College of Radiology recommend that women between the ages of 40 and 49 get mammograms every two years. However, The U.S. Preventive Services Task Force recommends mammograms only for women over age 50. The Task Force states that the benefits of mammography before age 50 do not outweigh the risks.
77055 Mammography; unilateral Office/Freestanding (Global) 2.52 $90.23 Facility (Professional) 1.00 $35.80 Facility (Technical) 1.52 $54.42
77056 Mammography; bilateral Office/Freestanding (Global) 3.24 $116.01 Facility (Professional) 1.24 $44.40 Facility (Technical) 2.00 $71.61
77057 Screening mammography, bilateral (2-view film study of each breast) Office/Freestanding (Global) 2.31 $82.71 Facility (Professional) 1.00 $35.80 Facility (Technical) 1.31 $46.90
Medicare covers one screening mammogram for women aged 40 years or older once every 12 months. CPT code 77057 (screening mammography, bilateral [two view film study of each breast]) is reported if a standard screening mammogram is performed. Medicare also covers computer aided detection (CAD) technology when performed in addition to the standard mammography. This service is reported using CPT add-on code +77052 (computer-aided detection (computer algorithm analysis of digital image data for lesion detection); screening mammography) in addition to code 77057. The Medicare deductible is waived for this service but the patient is responsible for 20% of the Medicare approved amount.
In April 2001, Medicare began to cover and provide additional payment for the use of digital technology for screening and diagnostic mammography studies. HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views) was developed to be reported for a screening full-field digital (FFDM) mammogram. Diagnosis code(s) V76.11 (screening mammogram for high-risk patient) or V76.12 (other screening mammogram) should be linked to the appropriate CPT-4 mammography code reported. The Medicare deductible is waived for this service but the patient is responsible for 20% of the Medicare approved amount.
A diagnostic mammogram (when the patient has an illness, disease or symptoms indicating the need for a mammogram) is covered whenever it is medically necessary.
Computer-Aided Detection (CAD) Add-On Codes
Effective for services on or after January 1, 2002 thr ugh December 31, 2003, (or April 1, 2002 for hospitals subject to OPPS) a new Procedure code 76085, CAD conversion of standard film images to digital images has been established as an add-on code that can be billed only in conjunction with the primary service screening mammography code 76092. The definition of 76085 is: “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, mammography (list separately in addition to code for primary procedure).”
NOTE: For claims with dates of service April 1, 2003 – December 31, 2003, code G0202 may be billed in conjunction with 76085.
Carriers and FIs make payment under the Medicare physician fee schedule. There is no Part B deductible. However, coinsurance is applicable.
For claims with dates of service April 1, 2005, and la er, hospitals bill for code 76082* (77051*) under the 13X bill type. The 14X bill type is no longer applicable. Appropriate TOBs for providers other than hospitals are 22X, 23X, and 85X.
Contractors must assure that claims containing code 76085 also contain HCPCS code 76092 or G0202. If not, FIs return claims to the provider with an explanation that payment for code 76085 cannot be made when billed alone. Carriers deny payment for 76085 when billed without 76092 or G0202.
NOTE: When screening CAD 76085 is billed in conjunction with a screening mammography (76092 or G0202) and the screening mammography (76092 or G0202) fails the age and frequency edits in CWF, both services will be rejected by CWF.
Effective with claims with dates of service January 1, 2004 thru December 31, 2006, HCPCS code 76083, “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with or without digitization of film radiographic images; screening mammography (list separately in addition
to code for primary procedure),” can be billed in conjunction with the primary service mammography code 76092 or G0202.
Effective with claims with dates of service January 1, 2007 and later, HCPCS code 77052, which replaces code 76083 “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with
or without digitization of film radiographic images; screening mammography (list separately in addition to code for primary procedure),” can be billed in conjunction with the primary service mammography code 77057 or G0202.
Contractors must assure that claims containing code 77052* (76083*) also contain HCPCS code 77057* (76092*) or G0202. FIs return claims containing code 77052* (76083*) that do not also contain HCPCS code 77057* (76092*) or G0202 with an explanation that payment for code 77052* (76083*) cannot be made when billed alone. Carriers deny payment for 77052* (76083*) when billed without 77057* (76092*) or G0202.
NOTE: When screening CAD 77052* (76083*) is billed in conjunction with a screening mammography (77057* (76092*) or G0202) and the screening mammography (77057* (76092*) or G0202) fails the age and frequency edits in CWF, both services will be rejected by CWF. *For claims with dates of service prior to January 1, 2007, providers report Procedure codes 76083 and 76092 or G0202. For claims with dates of service January 1, 2007 and later, providers report Procedure codes 77052 and 77057 or G0202, respectively.
Diagnostic Add-on Codes G0236 and 77051* (76082*) Effective for services on or after January 1, 2002 thru December 31, 2003, (or April 1, 2002 for hospital claims subject to OPPS), HCPCS code G0236 was established for diagnostic mammography CAD that can be billed only on the same claim with the primary service of either 76090 or 76091. The definition of G0236 is: “Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation.”
The code must be listed separately in addition to code for the primary procedure.
NOTE: For claims with dates of service April 1, 2003 - December 31, 2003, code G0204 and G0206 may be billed in conjunction with G0236.
For claims with dates of service April 1, 2005, and later, hospitals bill for code 76082* (77051*) under the 13X bill type. The 14X bill type is no longer applicable. Appropriate TOBs for providers other than hospitals are 22X, 23X, and 85X.
There are no frequency limitations on film or digital diagnostic tests or CAD-diagnostic tests. Contractors must assure that claims containing code G0236 also contain HCPCS code 76090, 76091, G0204, or G0206. If not, FIs return claims to the provider with an explanation that payment for code G0236 cannot be made when billed alone. Carriers deny payment for G0236 when billed without 76090, 76091, G0204, or G0206.
Effective with claims with dates of service January 1, 2004 thru December 31, 2006, HCPCS code 76082, “Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation with or without digitization of film radiographic images; diagnostic mammography (list separately in ddition to code for primary procedure),” can be billed in conjunction with the primary service mammography code 76090, 76091, G0204, or G0206.
Effective Date: January 1, 2007
Implementation Date: January 2, 2007
I. GENERAL INFORMATION
A. Background: New 2007 Current Procedural Terminology (CPT) mammography codes have been assigned for screening and diagnostic mammography services. These codes will replace the current CPT codes; however the CPT code descriptors for the services are unchanged.
B. Policy: : Effective for claims with dates of service January 1, 2007 and later, providers report new CPT codes 77051, 77052, 77055, 77056, and 77057 in place of current CPT codes 76082, 76083, 76090, 76091, and 76092 respectively.
II. BUSINESS REQUIREMENTS Use “Shall" to denote a mandatory requirement Number Requirement Responsibility (place an “X” in each applicable column) SharedSystem
5327.1 Upon release of the 2007 CPT codes by the American Medical Association (AMA), contractors shall advise providers that effective for claims with dates of service January 1, 2007 and later, the following new CPT codes have been assigned to mammography services:
77051 77052 77055 77056 77057
The CPT code descriptors for the services are unchanged.
X X X 5327.2 Contractors shall advise providers to report new X X X
Number Requirement Responsibility (place an “X” in each applicable column) SharedSystem codes for mammography claims effective January 1, 2007 as follows:
• report code 77051 in place of code 76082;
•report code 77052 in place of code 76083;
• report code 77055 in place of code 76090;
• report code 77056 in place of code 76091;
• report code 77057 in place of code 76092;
5327.2.1 Contractors shall use the following type of service (TOS) for the new codes:
77051—TOS 4
77052—TOS 1
77055---TOS 4
77056---TOS 4
77057---TOS 1
X X X 5327.3 Contractors shall return to providers claims with dates of service on or after January 1, 2007, containing CPT codes 76082, 76083, 76090, 76091, or 76092. X X X X X OPPS/ OCE
5327.4 Contractors and CWF shall update their systems to discontinue CPT codes 76082, 76083, 76090, 76091, and 76092 and replace them with new CPT codes 77051, 77052, 77055, 77056, and 77057 respectively. X X X X X X
5327.5 Contractors shall update any edits in their systems that contain CPT codes 76082, 76083, 76090, 76091, 76092 to replace them with CPT codes 77051, 77052, 77055, 77056, and 77057 respectively. X X X X X X
5327.6 CWF shall apply existing frequency standards for new screening mammography CPT codes 7052 and 77057 effective January 1, 2007. X
J. Breast (Incision, Excision, Introduction, Repair and Reconstruction)
1. Since a mastectomy (CPT codes 19300-19307) describes removal of breast tissue including all lesions within the breast tissue, breast excision codes (19110-19126) generally are not separately reportable unless performed at a site unrelated to the mastectomy. However, if the breast excision procedure precedes the mastectomy for the purpose of obtaining tissue for pathologic examination which determines the need for the mastectomy, the breast excision and mastectomy codes are separately reportable.
(Modifier 58 may be utilized to indicate that the procedures were staged.) If a diagnosis was established preoperatively, an excision procedure for the purpose of obtaining additional pathologic material is not separately reportable.
Similarly, diagnostic biopsies (e.g., fine needle aspiration, core, incisional) to procure tissue for diagnostic purposes to determine whether an excision or mastectomy is necessary at the same patient encounter may be reported with modifier 58 appended to the excision or mastectomy code. However, biopsies (e.g.,Revision Date (Medicare): 1/1/2014 III-11 fine needle aspiration, core, incisional) are not separately reportable if a preoperative diagnosis exists.
2. The breast procedure codes include incision and closure. Some codes describe mastectomy procedures with ymphadenectomy and/or removal of muscle tissue. The latter procedures are not separately reportable. Except for sentinel lymph node biopsies, ipsilateral lymph node excisions are not separately reportable. Contralateral lymph node excisions may be
separately reportable with appropriate modifiers (i.e., LT, RT).
3. Sentinel lymph node biopsy is separately reportable when performed prior to a localized excision of breast or a mastectomy without lymphadenectomy. However, sentinel lymph node biopsy is not separately reportable with a mastectomy procedure that includes lymphadenectomy in the anatomic area of the sentinel lymph node biopsy. Open biopsy or excision of sentinel lymph node(s) should be reported as follows: axillary (CPT codes 38500 or 38525), deep cervical (CPT code 38510), internal mammary (CPT code 38530). (CPT code 38740(axillary lymphadenectomy; superficial) should not be reported for a sentinel lymph node biopsy. Sentinel lymph node biopsy of superficial axillary lymph node(s) is correctly reported as CPT code 38500 (biopsy or excision of lymph node(s), superficial) which includes the removal of one or more discretely identified superficial lymph nodes. By contrast a superficial axillary lymphadenectomy (CPT code 38740) requires removal of all superficial axillary adipose tissue with all lymph nodes in this adipose tissue.)
4. Breast reconstruction codes that include the insertion of a prosthetic implant should not be reported with codes that separately describe the insertion of a breast prosthesis.
5. CPT codes for breast procedures generally describe unilateral procedures.
6. If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed withmammographic guidance (e.g., 19281,19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.
Benefits for Mammography Screening - BCBS
Benefits are available for a screening by low-dose mammography for the presence of occult breast cancer for a Participant 35 years of age and older, as shown on your Schedule of Coverage, except that benefits will not be available for more than one routine mammography screening each Calendar Year.
Diagnostic Mammography
A diagnostic mammography is a radiological mammogram and is a covered diagnostic test under the following conditions:
• A patient has distinct signs and symptoms for which a mammogram is indicated;
• A patient has a history of breast cancer; or
• A patient is asymptomatic, but based on the patient’s history and other factors the
physician considers significant, the physician’s judgment is that a mammogram is appropriate.
• Beginning January 1, 2005, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, §644, Public Law 108-173 has changed the way Medicare pays for diagnostic mammography. Medicare will pay based on the MPFS in lieu of OPPS or the lower of the actual change.
Billing Requirements - A/B MAC (A) Claims
(Rev. 1519, Issued: 05-30-08, Effective: 05-23-08, Implementation: 06-30-08) A/B MACs use the weekly-updated MQSA file to verify that the billing facility is certified by the FDA to perform mammography services, and has the appropriate certification to perform the type of mammogram billed (film and/or digital). (See §20.1.) A/B MACs (A) use the provider number submitted on the claim to identify the facility and use the MQSA data file to verify the facility’s certification(s). A/B MAC (A) complete the following activities in processing mammography claims:
• If the provider number on the claim does not correspond with a certified mammography facility on the MQSA file, then A/B MACs (A) deny the claim.
• When a film mammography HCPCS code is on a claim, the claim is checked for a “1” film indicator.
• If a film mammography HCPCS code comes in on a claim and the facility is certified for film mammography, the claim is paid if all other relevant Medicare criteria are met.
• If a film mammography HCPCS code is on a claim and the facility is certified for digital mammography only, the claim is denied.
• When a digital mammography HCPCS code is on a claim, the claim is checked for “2” digital indicator.
• If a digital mammography HCPCS code is on a claim and the facility is certified for digital mammography, the claim is paid if all other relevant Medicare criteria are met.
• If a digital mammography HCPCS code is on a claim and the facility is certified for film mammography only, the claim is denied.
NOTE: The Common Working File (CWF) no longer receives the mammography file for editing purposes.
Except as provided in the following sections for RHCs and FQHCs, the following procedures apply to billing for screening mammographies:
The technical component portion of the screening mammography is billed on Form CMS- 1450 under bill type 12X, 13X, 14X**, 22X, 23X or 85X using revenue code 0403 and HCPCS code 77057* (76092*).
The technical component portion of the diagnostic mammography is billed on Form CMS-1450 under bill type 12X, 13X, 14X**, 22X, 23X or 85X using revenue code 0401 and HCPCS code 77055* (76090*), 77056* (76091*), G0204 and G0206.
Separate bills are required for claims for screening mammographies with dates of service prior to January 1, 2002. Providers include on the bill only charges for the screening mammography. Separate bills are not required for claims for screening mammographies with dates of service on or after January 1, 2002. See separate instructions below for rural health clinics (RHCs) and federally qualified health centers (FQHCs).
* For claims with dates of service prior to January 1, 2007, providers report CPT codes 76090, 76091, and 76092. For claims with dates of service January 1, 2007 and later, providers report CPT codes 77055, 77056, and 77057 respectively.** For claims with dates of service April 1, 2005 and later, hospitals bill for all mammography services under the 13X type of bill or for dates of service April 1, 2007 and later, 12X or 13X as appropriate. The 14X type of bill is no longer applicable.
Appropriate bill types for providers other than hospitals are 22X, 23X, and 85X.
In cases where screening mammography services are self-referred and as a result an attending physician NPI is not available, the provider shall duplicate their facility NPI in the attending physician identifier field on the claim.
A/B MACs (B) complete the type of service field in the CWF Part B claim record with a “B” if the patient is a high risk screening mammography patient or a “C” if she is a low risk screening mammography patient for services prior to January 1, 1998.
For services on or after January 1, 1998, the type of service field on CWF must have a value of “1” for medical care (screening) or a “4” for diagnostic radiology (diagnostic). Fill in POS. Fill in deductible indicator field with a “1”; not subject to deductible if screening mammography. Submit the claim to the CWF host. Trailer 17 of the Part B Basic Reply record will give the date of the last screening mammography. The CWF edits for age and frequency for screening mammography. There are no frequency limitations on diagnostic tests or CAD-diagnostic tests. When a screening CAD is billed in conjunction with a screening mammogram and the screening mammogram fails the age or frequency edits then both services will be rejected.
Claims With Dates of Service October 1, 1998 Through December 31, 2001
A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while the beneficiary is still at the facility for the screening exam. Where a radiologist interpretation results in additional films, the mammography is no longer considered a screening exam for application of age and frequency standards or for payment purposes. This can be done without an additional order from the treating physician. When this occurs, the claim will be billed and paid as a diagnostic mammography instead of a screening mammography. However, since the original intent for the exam was for screening, for statistical purposes, the claim is considered a screening.
The claim should be prepared for A/B MAC (A) processing reflecting the diagnostic revenue code (0401) along with HCPCS code 76090, 76091, G0204, G0206 or G0236 as appropriate and modifier “-GH” “Diagnostic mammogram converted from screening mammogram on same day.” Statistics will be collected based on the presence of modifier “-GH.” A separate claim is not required. Regular billing instructions remain in place for mammograms that do not fit this situation. A/B MACs (B) should receive a claim for a screening mammogram with CPT code 76092 (screening mammography, bilateral) (Type of Service = 1) but, if the screening
mammogram turns into a diagnostic mammogram, the claim is billed with CPT code 76090 (unilateral) or 76091 (bilateral), (TOS= 4), with the “-GH” modifier. A/B MACs (B) pay the claim as a diagnostic mammography instead of a screening mammography.
NOTE: However, the ordering of a diagnostic test by a radiologist following a screening test that shows a potential problem need not be on the same date of service.
In this case, where additional diagnostic tests are performed for the same beneficiary, same visit on the same day, the UPIN of the treating physician is needed on the A/B MACs (B) claim. The radiologist must refer back to the treating physician for his/her UPIN and also report to the treating physician the condition of the patient. A/B MACs (B) need to educate radiologists and treating physicians that the treating physician’s UPIN is required whenever a physician refers or orders a diagnostic lab or radiology service. If no UPIN is present for the diagnostic mammography code, the A/B MACs (B) will reject the claim
Claims With Dates of Service On or After January 1, 2002, (or On or After April 1, 2002 for Hospitals Subject to OPPS)
A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam. When a radiologist’s interpretation results in additional films, Medicare will pay for both the screening and diagnostic mammogram.
A/B MACs (B) Claims
For A/B MACs (B) claims, providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier “- GG” to the diagnostic mammography. A modifier “-GG” is appended to the claim for the diagnostic mammogram for tracking and data collection purposes. Medicare will reimburse both the screening mammography and the diagnostic mammography.
A/B MAC (A) Claims
A/B MACs (A) require the diagnostic claim be prepared reflecting the diagnostic revenue code (0401) along with HCPCS code 77055* (76090*), 77056* (76091*), G0204, G0206 or G0236 and modifier “-GG” “Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.” Reporting of this modifier is needed for data collection purposes. Regular billing instructions remain in place for a screening mammography that does not fit this situation. Both A/B MACs (A) and (B) systems must accept the GH and GG modifiers where appropriate.
* For claims with dates of service prior to January 1, 2007, providers report CPT codes
76090 and 76091. For claims with dates of service January 1, 2007 and later, providers report CPT codes 77055 and 77056 respectively.
Mammograms Performed With New Technologies
(Rev. 1070, Issued: 09-29-06, Effective: 01-01-07, Implementation: 01-02-07) Section 104 of the Benefits Improvement and Protection Act 2000, (BIPA) entitled Modernization of Screening Mammography Benefit, provides for new payment methodologies for both diagnostic and screening mammograms that utilize advanced new technologies for the period April 1, 2001, to December 31, 2001 (to March 31, 2002 for hospitals subject to OPPS). Under this provision, payment for technologies that directly take digital images would equal 150 percent of the amount that would otherwise be paid for a bilateral diagnostic mammography. For technologies that convert standard film images to digital form, payment will be derived from the statutory screening mammography limit plus an additional payment of $15.00 for A/B MACs (B) claims and $10.20 for A/B MAC (A) (technical component only) claims.
Payment restrictions for digital screening and diagnostic mammography apply to those facilities that meet all FDA certifications as provided under the Mammography Quality Standards Act. However, CAD codes billed in conjunction with digital mammographies or film mammographies are not subject to FDA certification requirements.
Mammography related CAD equipment does not require FDA certification.
Mammography utilizes a direct x-ray of the breast. By contrast, the CAD process uses laser beam to scan the mammography film from a film (analog) mammography, converts it into digital data for the computer, and analyzes the video display for areas suspicious for cancer. The CAD process used with digital mammography analyzes the data from the mammography on a video display for suspicious areas. The patient is not required to be present for the CAD process.
Only one screening mammogram, either 77057* (76092*) or G0202, may be billed in a calendar year. Therefore, providers/suppliers must not submit claims reflecting both a film screening mammography (77057* (76092*)) and a digital screening mammography G0202. Also, they must not submit claims reflecting HCPCS codes 77055* (76090*) or
77056* (76091*) (diagnostic mammography-film) and G0204 or G0206 (diagnostic mammography-digital). MACs deny the claim when both a film and digital screening or diagnostic mammography is reported. However, a screening and diagnostic mammography can be billed together.
* For claims with dates of service prior to January 1, 2007, providers report CPT codes 76090, 76091, and 76092. For claims with dates of service January 1, 2007 and later, providers report CPT codes 77055, 77056, and 77057 respectively.
HCPCS Definition
G0202 Screening mammography producing direct digital image, bilateral, all views
Payment Method:
Payment will be the lesser of the provider’s charge or the amount that will be provided for this code in the pricing file. (That amount is 150 percent of the locality specific technical component payment amount under the physician fee schedule for CPT code 76091, the code for bilateral diagnostic mammogram, during 2001.) Part B deductible does not apply. Coinsurance will equal 20 percent of the lesser of the actual charge or 150 percent of the locality specific payment of CPT code 76091.
HCPCS Definition
G0204 Diagnostic mammography, direct digital image, bilateral, all views
Payment Method:
Payment will be the lesser of the provider’s charge or the amount that will be provided for this code in the pricing file. (That amount is 150 percent of the locality specific amount paid under the physician fee schedule for the technical component (TC) of CPT code 76091, the code for a bilateral diagnostic mammogram.) Deductible is applicable. Coinsurance will equal 20 percent of the lesser of the actual charge or 150 percent of the locality specific payment of CPT code 76091.
NOTE: Effective January 1, 2005, payment will be made under MPFS for claims from hospitals subject to OPPS.
HCPCS Definition
G0206 Diagnostic mammography, direct digital image, unilateral, all views.
Payment Method:
Payment will be made based on the same amount that is paid to the provider, under the payment method applicable to the specific provider type (e.g., hospital, rural health clinic, etc.) for CPT code 76090, the code for a mammogram, and one breast. For example, this service, when furnished as a hospital outpatient service, will be paid the amount under the outpatient prospective payment system (OPPS) for CPT code 76090. Deductible applies. Coinsurance is the national unadjusted coinsurance for the APC wage adjusted for the specific hospital. NOTE: Effective January 1, 2005, payment will be made under MPFS for claims from hospitals subject to OPPS.
HCPCS Definition
G0207 Diagnostic mammography, film processed to produce digital image analyzed for potential abnormalities, unilateral, all views.
Payment Method:
Payment will be based on the same amount that is paid to the provider, under the payment method applicable to the specific provider type (e.g., hospital, rural health clinic, etc.) for CPT code 76090, the code for mammogram, and one breast. For example, this service, when furnished as a hospital outpatient service, will be paid the amount payable under the OPPS for CPT code 76090. Deductible applies. Coinsurance is the national unadjusted coinsurance for the APC wage adjusted for the specific hospital.
Providers bill for the technical portion of screening and diagnostic mammograms on Form CMS-1450 under bill type 13X, 22X, 23X, or 85X. The professional component is billed to the A/B MACs (B) on Form CMS-1500 (or electronic equivalent). Providers bill for digital screening mammographies on Form CMS-1450, utilizing revenue code 0403 and HCPCS G0202 or G0203. Providers bill for digital diagnostic mammographies on Form CMS-1450, utilizing revenue code 0401 and HCPCS G0204, G0205, G0206 or G0207. NOTE: Codes G0203, G0205 and G0207 are not billable codes for claims with dates of service on or after January 1, 2002.
Screening mammograms are covered annually for women 40 years of age and older. The Spanish version of this MSN message should read: El examen de mamografÃa de cernimiento se cubre una vez al año para mujeres de 40 años de edad o más. For A/B MACs (B) only: For claims submitted with invalid or missing certification number, use the following MSN: MSN 9.2:
This item or service was denied because information required to make payment was missing.
For claims submitted by a facility not certified to perform digital mammograms, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.
What is a mammagrom?
Mammography is an x-ray imaging method used to examine the breast for the early detection of cancer and other breast diseases. It is used as both a diagnostic and screening tool.
How does it work?
During a mammogram, a patient’s breast is placed on a flat support plate and compressed with a parallel plate called a paddle. An x-ray machine produces a small burst of x-rays that pass through the breast to a detector located on the opposite side. The detector can be either a photographic film plate, which captures the x-ray image on film, or a solid-state detector, which transmits electronic signals to a computer to form a digital image. The images produced are called mammograms. On a film mammogram, areas of low density, such as fatty tissue, appear translucent (i.e. similar to the black background)., whereas areas of dense tissue, such as connective and glandular tissue or tumors, appear whiter on a black background. In a standard mammogram, both a top and a side view are taken of each breast, although extra views may be taken if the physician is concerned about a particular area of the breast.
What will the results look like?
A radiologist will carefully examine a mammogram to search for areas or types of tissue that look different from normal tissue. These areas could represent many different types of abnormalities, including cancerous tumors, non-cancerous masses called benign tumors, fibroadenomas, or complex cysts. Radiologists look at the size, shape, and contrast of a mass, as well as the edges or margins, which can indicate the possibility of malignancy (i.e. cancer). They also look for tiny bits of calcium, called microcalcifications, which show up as very bright specks on a mammogram. While usually benign, microcalcifications may occasionally indicate the presence of a specific type of cancer. If a mammogram is abnormal, the radiologist may order additional mammogram views, as well as additional magnification or compression, and if suspicious areas are detected, he/she may order a biopsy.
What is digital mammography?
A digital mammogram uses the same x-ray technology as conventional mammograms, but instead of using film, solid-state detectors are used. These detectors convert the x-rays that pass through them into electronic signals that are sent to a computer. The computer then converts these electronic signals into images that can be displayed on a monitor and also stored for later use. Several advantages of using digital mammography over film mammography include: the ability to manipulate the image contrast for better clarity, the ability to use computer-aided diagnosis, and the ability to easily transmit digital files to other experts for a second opinion. In addition, digital mammograms may decrease the need for the re-takes, which are common with film mammography due to incorrect exposure techniques or problems with film development. As a result, digital mammography can lead to lower effective patient x-ray exposures.
In 2005, results from a large clinical trial sponsored by the National Cancer Institute found that digital mammography was superior to film mammography for the following populations[1]
• Women under 50
• Women with dense breasts
• Women who have not gone through menopause or who have been in menopause less than one year
What are the limits of mammography?
For certain types of breasts, mammograms can be difficult to interpret. This is because there is a wide variation in breast tissue density among women. Denser breasts are more difficult to image, and more difficult to diagnose. For this and other reasons, the sensitivity of mammography in detecting cancer can vary over a wide range. For many difficult cases, x-ray mammography alone may not be sufficiently sensitive or accurate in detecting cancer, so additional imaging technologies, such as ultrasound
What are the limits of mammography?
For certain types of breasts, mammograms can be difficult to interpret. This is because there is a wide variation in breast tissue density among women. Denser breasts are more difficult to image, and more difficult to diagnose. For this and other reasons, the sensitivity of mammography in detecting cancer can vary over a wide range. For many difficult cases, x-ray mammography alone may not be sufficiently sensitive or accurate in detecting cancer, so additional imaging technologies, such as ultrasound or magnetic resonance imaging (MRI) may also be used to increase the sensitivity of the exam. Finally, although the majority of abnormal mammograms are false-positives, when cancer is present, early detection can save lives.
Are there risks?
Because mammography uses x-rays to produce images of the breast, patients are exposed to a small amount of ionizing radiation. The risk associated with this dose appears to be greater among younger women (under age 40). However, in some cases, the benefits of using mammography to detect breast cancer under age 40 may outweigh the risks of radiation exposure. For example, a mammogram may reveal that a suspicious mass is benign and, therefore, doesn’t need to be treated. Additionally, if a tumor is malignant and is caught early by mammogram, a surgeon may be able to remove it before it spreads and requires more aggressive treatment such as chemotherapy.Different groups provide different guidelines for mammography. For instance, the American Cancer Society as well as the American College of Radiology recommend that women between the ages of 40 and 49 get mammograms every two years. However, The U.S. Preventive Services Task Force recommends mammograms only for women over age 50. The Task Force states that the benefits of mammography before age 50 do not outweigh the risks.
MEDICARE PREVENTIVE SERVICES CPT 77078,77079, 77081
OTHER MEDICARE PREVENTIVE SERVICES
Following are brief descriptions of other preventive services covered by Medicare and sometimes provided by obstetrician/gynecologists.
Bone Mass Measurements
Medicare covers bone mass measurements every two years for qualified individuals. The patient is responsible for meeting her Medicare Part B deductible and for her 20% co-payment.
A “qualified individual” meets at least one of these medical indications:
• Estrogen-deficient and at clinical risk for osteoporosis
• Vertebral abnormalities as demonstrated by an x-ray
• Receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5.0 mg of prednisone or greater, per day, for more than 3 months
• Has a diagnosis of primary hyperparathyroidism
• Being monitored to assess the response to or efficacy of an FDA – approved osteoporosis drug therapy
Medicare may pay for more frequent screenings when medically necessary. Examples include, but are not limited to, the following medical circumstances:
• Monitoring beneficiaries on long-term (more than 3 months) glucocorticoid (steroid) therapy
• Confirming baseline BMMs to permit monitoring of beneficiaries in the future
Procedure Codes
Medicare allows the physician to choose the screening test. As of January 1, 2007, the CPT/HCPCS coding options are:
77078 Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
77079 appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77080 Dual energy x-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77083 Radiographic absorptiometry (photodensitometry, radiogrammetry), one or more sites
76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method
G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites, appendicular skeleton (peripheral; e.g., radius, wrist, heel)
Diagnosis Codes
Local carriers determine the ICD-9-CM diagnostic codes that they will accept as supporting these indications. The test must be ordered by a physician or a qualified nonphysician practitioner who is treating the patient. Qualified nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and nurse-midwives. The test results must be required as part of the patient’s evaluation and/or formulation of a treatment plan.
Following are brief descriptions of other preventive services covered by Medicare and sometimes provided by obstetrician/gynecologists.
Bone Mass Measurements
Medicare covers bone mass measurements every two years for qualified individuals. The patient is responsible for meeting her Medicare Part B deductible and for her 20% co-payment.
A “qualified individual” meets at least one of these medical indications:
• Estrogen-deficient and at clinical risk for osteoporosis
• Vertebral abnormalities as demonstrated by an x-ray
• Receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5.0 mg of prednisone or greater, per day, for more than 3 months
• Has a diagnosis of primary hyperparathyroidism
• Being monitored to assess the response to or efficacy of an FDA – approved osteoporosis drug therapy
Medicare may pay for more frequent screenings when medically necessary. Examples include, but are not limited to, the following medical circumstances:
• Monitoring beneficiaries on long-term (more than 3 months) glucocorticoid (steroid) therapy
• Confirming baseline BMMs to permit monitoring of beneficiaries in the future
Procedure Codes
Medicare allows the physician to choose the screening test. As of January 1, 2007, the CPT/HCPCS coding options are:
77078 Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
77079 appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77080 Dual energy x-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77083 Radiographic absorptiometry (photodensitometry, radiogrammetry), one or more sites
76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method
G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites, appendicular skeleton (peripheral; e.g., radius, wrist, heel)
Diagnosis Codes
Local carriers determine the ICD-9-CM diagnostic codes that they will accept as supporting these indications. The test must be ordered by a physician or a qualified nonphysician practitioner who is treating the patient. Qualified nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and nurse-midwives. The test results must be required as part of the patient’s evaluation and/or formulation of a treatment plan.
Medicare will cover physical exam code - G0438, G0439
Effective 2011, Medicare would cover for physical examinations and below are the two new codes. Please have this updated in the respective software and fee schedule.
New CPT codes to report Annual Wellness Visit (only for Medicare)
G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first)
G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq)
Medicare Diabetes Screening guideline - CPT 82947, 82950 , 82951
Diabetes Screening
The diabetes screening tests include a fasting blood glucose test, post-glucose challenge tests, and either an oral glucose tolerance test with a glucose challenge of 75 grams of glucose for non-pregnant adults or a 2-hour post-glucose challenge test alone. This screening is covered twice within a 12-month period.
Individuals are eligible for the benefit if they have the following risk factors:
• Hypertension.
• Dyslipidemia.
• Obesity (body mass index 30 kg/m2 or more).
• Previous identification of an elevated impaired fasting glucose or glucose tolerance.
• At least two of the following:
o Overweight (body mass index greater than 25 kg/m2, but less than 30).
o A family history of diabetes.
o A history of gestational diabetes mellitus or delivery of a baby weighing greater than 9 pounds.
o 65 years of age or older.
Patients previously diagnosed as diabetic are not covered. Individuals diagnosed as pre-diabetic are eligible for this benefit. Pre-diabetes is defined as a fasting glucose level of 100-125 mg/dL, or a 2 hour post-glucose challenge of 140-199 mg/dL. Individuals not meeting the pre-diabetes criteria are eligible for one screening test per year.
Medicare covers these tests when reported with diagnosis code V77.1 (screening for diabetes mellitus) and one of the following CPT codes:
• 82947 - Glucose; quantitative, blood (except reagent strip)
• 82950 - Glucose; post glucose dose (includes glucose)
• 82951 - Glucose; tolerance test (GTT), three specimens (includes glucose)
The diabetes screening tests include a fasting blood glucose test, post-glucose challenge tests, and either an oral glucose tolerance test with a glucose challenge of 75 grams of glucose for non-pregnant adults or a 2-hour post-glucose challenge test alone. This screening is covered twice within a 12-month period.
Individuals are eligible for the benefit if they have the following risk factors:
• Hypertension.
• Dyslipidemia.
• Obesity (body mass index 30 kg/m2 or more).
• Previous identification of an elevated impaired fasting glucose or glucose tolerance.
• At least two of the following:
o Overweight (body mass index greater than 25 kg/m2, but less than 30).
o A family history of diabetes.
o A history of gestational diabetes mellitus or delivery of a baby weighing greater than 9 pounds.
o 65 years of age or older.
Patients previously diagnosed as diabetic are not covered. Individuals diagnosed as pre-diabetic are eligible for this benefit. Pre-diabetes is defined as a fasting glucose level of 100-125 mg/dL, or a 2 hour post-glucose challenge of 140-199 mg/dL. Individuals not meeting the pre-diabetes criteria are eligible for one screening test per year.
Medicare covers these tests when reported with diagnosis code V77.1 (screening for diabetes mellitus) and one of the following CPT codes:
• 82947 - Glucose; quantitative, blood (except reagent strip)
• 82950 - Glucose; post glucose dose (includes glucose)
• 82951 - Glucose; tolerance test (GTT), three specimens (includes glucose)
CPT 99393, 99394, 99395, 99396 - 99397 - screen services - Does Medicare cover ?
99393 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years)
99394 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)
99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99397 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older
Medicare Screening Services
Physicians are often confused about how to document and report preventive services provided to their Medicare patients. This document is designed to assist physicians in documenting, reporting and receiving reimbursement for these services.
Medicare does not cover comprehensive preventive visits (99381-99397). However, Medicare does cover certain screening services which are often performed during preventive visits such as:
• Screening pelvic exam
• Collection of screening Pap smear specimen
• Interpretation of the Pap smear test (reported by the laboratory)
• Screening hemoccult
• Screening mammography
• Screening bone mass measurement
• Initial preventive physical examination (Welcome to Medicare examination)
• Diabetes screening
• Cardiovascular blood test
• Tobacco use cessation counseling
The table at the end of this document provides an overview of Medicare screening services. The Centers for Medicare and Medicaid (CMS) have published several educational products that describe covered screening services available to Medicare patients.
OVERVIEW
Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse the Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.
When a Preventive Medicine service and Other E/M services are provided during the same visit, only the Preventive Medicine service will be reimbursed.
Screening services include cervical cancer screening; pelvic and breast examination; prostate cancer screening/digital rectal examination; and obtaining, preparing and conveyance of a Papanicolaou smear to the laboratory. These Screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine service rendered on the same day.
Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes.
Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes.
Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes.
Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.
Preventive Medicine Visits
• Not all insurers pay for preventive medicine visits. For example, these visits are not covered by Medicare. If you suspect a patient does not have coverage, advise him or her of your billing policies.
• Insurers that do cover preventive medicine visits (eg, many HMOs) generally reimburse them at relatively high rates.
• Regardless of whether a preventive medicine visit is covered, the relevant codes can be used alone or in conjunction with a code for an E&M service (see below).
Patient and Visit Preventive Medicine Code New patient, initial visit
Age 40 through 64 years 99386
Age 65 years and older 99387 Established patient, periodic visit Age 40 through 64 years 99396
Age 65 years and older 99397
Coding and Billing
Preventive Medicine Visits in Conjunction with an E&M Service
What should you do when you find a problem during an otherwise preventive medicine visit?
• Select the appropriate preventive medicine code and the E&M code that best represents the problems addressed.
Example CPT Code Charge Preventive medicine visit Established patient, over 65 years old 99397 $225
Office visit, level 4 99214 $175 The patient will owe the difference if he or she has Medicare and a secondary insurance. 5 – $175 = $50 Medicare allowable for a level 4 visit $87.78 Medicare pays 80% $70.22 Patient or secondary insurance pays
remaining 20% $17.56
Patient total out-of-pocket may be up to $50 + $17.56 = $67.50
Note: Medigap will pay the secondary insurance amount but not the additional charge for the preventive medicine service that is not covered.
• Do not increase the level of the code for the E&M service to account for preventive medicine efforts.
Preventive Services Covered Under the Affordable Care Act CPT CODE(S) (Append Modifier 33 to services that are not inherently reventive to i dicate an ACA service e.g. 99201-99215) HCPCS CODE(S) (Medicare & some commercial payers) Suggested ICD9 CODE(S) (In order of preference) Note: Most private payers expect that these preventive services (counseling, screening and immunizations) occur during the annual preventive exam and may not reimburse separately for these on the same day nor at subsequent visits.
* CMS billing guidelines indicate Physician or Advanced Practice Practitioners may use modifier 25 with modifier EP or modifier TJ for preventive medicine service codes (99381 - 99397 and additional screening codes 99406-99409 and 99420) when reported in conjunction with immunization administrative services (90460-99474). Physician or Advanced Practice Practitioners may submit corrected replacement claims if appropriate.
* Modifier 25 may be used with other non-preventive medicine E/M services when reported in conjunction with immunization administration when the E/M service is significant and separately identifiable. Exception: If a vaccine is billed with the same date of service as code 99211, NCCI edits do not permit the E/M code to be reimbursed. CMS has stated that an E/M code should not be billed in addition to the administration code(s) when the beneficiary presents for vaccine(s) only.
* CMS billing guidelines indicate Physician or Advanced Practice Practitioners may use modifier 25 with modifier EP or modifier TJ for preventive medicine service codes (99381 - 99397 and additional screening codes 99406-99409 and 99420) when reported in conjunction with immunization administrative services (90460-99474). Physician or Advanced Practice Practitioners may submit corrected replacement claims if appropriate.
99381, 99382, 99383, 99384, 99385, 99386, 99387 (Preventive visits for new patients by age)
G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment)
V70.0 (Routine general exam)
99391, 99392, 99393, 99394, 99395, 99396, 99397(Preventive visits for established patients by age)
G0438 (Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit)
V72.31 (Routine gyn exam)
G0439 (Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit)
S0610 (Annual gynecological examination, new patient)
S0612 (Annual gynecological examination, established patient)
S0613 (Annual gynecological examination; clinical breast examination without pelvic evaluation)
EPSDT CPT codes well-child visits STAGE (Age) NEW PATIENT CPT CODE
ESTABLISHED PATIENT CPT CODE
INFANCY (Prenatal – 9 months) 99381 99391
EARLY CHILDHOOD (12 months – 4 years) 99382 99392
MIDDLE CHILDHOOD (5 years – 10 years) 99383 99393
ADOLESCENCE STAGE 1 (11 years – 17 years) 99384 99394
ADOLESCENCE STAGE 2 (18 years – 21 years) 99385 99395
EPSDT CPT codes for sensory screening
SERVICE CPT CODE
VISION 99173
HEARING (Audio) 92551
HEARING (Pure tone-air only) 92552
Adult annual preventive care visits
New patient
CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years
CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years
CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older
Established patient
CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years
CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years
CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older
Adolescent annual preventive care visits
New patient
CPT Code 99382: Initial Preventive Medicine New Patient age 1-4 years
CPT Code 99383: Initial Preventive Medicine New Patient age 5-11 years
CPT Code 99384: Initial Preventive Medicine New Patient age 12-17 years
Established patient
CPT Code 99392: Periodic Preventive Medicine Established Patient age 1-4 years
CPT Code 99393: Periodic Preventive Medicine Established Patient age 5-11 years
CPT Code 99394: Periodic Preventive Medicine Established Patient age 12-17 years
EPSDT codes PLUS Evaluation and Management (E&M) codes PLUS Modifier 25* PLUS
ICD-9 Diagnosis codes 99381–99385 or 99391-99395 The components of the EPSDT visit must be provided and documented. 99203–99215 The presenting problem must be of moderate to high severity. Documentation must support the use of modifier 25. V20.2 or V70.0 must be the primary diagnosis diagnosis code for the visit. Add the diagnosis codes for the presenting problem focused evaluation
*If a patient is evaluated and treated for a problem during the same visit as an EPSDT exam, the problem-oriented exam can be billed along with the EPSDT visit when accompanied by the 25 modifier. Modifier 25 means that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day of the procedure or other service which was provided. In other words, two services were provided on the same day by the same provider, which could have been billed separately if the patient had been seen on two separate dates
Limitations for added procedure code: Procedure codes 96160 and 96161 replace discontinued procedure code 99420 and may be reimbursed for services rendered to clients who are 12 through 18 years of age as follows:
• To NP, CNS, PA, physician, and FQHC providers for services rendered in the office setting. Procedure codes 96160 and 96161 will be denied if billed with the same date of service as procedure codes 99384, 99385, 99394, and 99395.
Providers must use procedure code 96160 or 96161 for the required mental health screening. Procedure codes 96160 and 96161 must be billed with the appropriate medical check-up procedure code. Only one procedure code (96160 or 96161) may be reimbursed once per lifetime.
Limitations for added procedure code: Discontinued procedure code 99420 has been replaced by added procedure codes 96160 and 96161. Procedure codes 96160 and 96161 may be reimbursed as follows:
• For services rendered to clients who are 12 through 18 years of age.
• To Federally Qualified Health Center (FQHC) and THSteps providers for THSteps services rendered in the office setting.
Mental health screening for behavioral, social, and emotional development is required at each THSteps checkup. Mental health screening using one of the validated, standardized mental health screening tools recognized by THSteps is required once for all clients who are 12 through 18 years of age.
A mental health screening must be submitted with procedure code 96160 for a screening tool completed by the adolescent, or procedure code 96161 for a screening tool completed by the parent or caregiver on behalf of the adolescent. When claims with procedure code 96160 or 96161 are submitted for mental health screenings, one of the validated, standardized mental health screening tools recognized by THSteps must be used.
Only one procedure code (96160 or 96161) may be reimbursed for the mental health screening per client per lifetime based on the description of the procedure code and the service rendered. Procedure codes 96160 and 96161 will not be reimbursed for the same client for any date of service. Procedure code 96160 or 96161 must be submitted with the same date of service by the same provider as procedure code 99384, 99385, 99394, or 99395. The client’s medical record must include documentation identifying the tool that was used, the screening results, and any referrals that are made.
EPSDT REQUIREMENTS FOR FLORIDA MMA
The Florida Agency for Health Care Administration (AHCA) requires providers to include the Child Health Check up modifier and referral code that identifies the health screening of a child on the CMS 1500 form and the 837P EDI. portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/Child_Health_Check-UpHB.pdf (starting page 36)
Billing Requirements:
A claim with a procedure code that falls within the procedure code range of 99381-99384 or 99391-99394 must also contain the appropriate referral condition code NU, AV, S2 or ST in Form Item Number 24H shaded for paper on the CMS 1500 form or the SV111 segment with a CRC qualifier for EDI.
A claim submitted with procedure codes 99385 or 99395 must meet the age requirement (ages 18-20), be billed with an EP modifier and contain the appropriate referral condition code NU, AV, S2 or ST.
The EPSDT referral indicator must be present for all codes that meet the FL State requirement of being a Child Health Check up code.
The EPSDT indicator referral condition codes AV, ST, S2 and NU, and Y/N family planning indicator requirements, are documented in the National Uniform Claim Committee (NUCC) billing guide for CMS 1500 and the X12N/005010X222 Professional 837P EDI guides. Please refer to the guides for correct billing requirements.
99394 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)
99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99397 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older
Medicare Screening Services
Physicians are often confused about how to document and report preventive services provided to their Medicare patients. This document is designed to assist physicians in documenting, reporting and receiving reimbursement for these services.
Medicare does not cover comprehensive preventive visits (99381-99397). However, Medicare does cover certain screening services which are often performed during preventive visits such as:
• Screening pelvic exam
• Collection of screening Pap smear specimen
• Interpretation of the Pap smear test (reported by the laboratory)
• Screening hemoccult
• Screening mammography
• Screening bone mass measurement
• Initial preventive physical examination (Welcome to Medicare examination)
• Diabetes screening
• Cardiovascular blood test
• Tobacco use cessation counseling
The table at the end of this document provides an overview of Medicare screening services. The Centers for Medicare and Medicaid (CMS) have published several educational products that describe covered screening services available to Medicare patients.
OVERVIEW
Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse the Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.
When a Preventive Medicine service and Other E/M services are provided during the same visit, only the Preventive Medicine service will be reimbursed.
Screening services include cervical cancer screening; pelvic and breast examination; prostate cancer screening/digital rectal examination; and obtaining, preparing and conveyance of a Papanicolaou smear to the laboratory. These Screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine service rendered on the same day.
Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes.
Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes.
Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes.
Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.
Preventive Medicine Visits
• Not all insurers pay for preventive medicine visits. For example, these visits are not covered by Medicare. If you suspect a patient does not have coverage, advise him or her of your billing policies.
• Insurers that do cover preventive medicine visits (eg, many HMOs) generally reimburse them at relatively high rates.
• Regardless of whether a preventive medicine visit is covered, the relevant codes can be used alone or in conjunction with a code for an E&M service (see below).
Patient and Visit Preventive Medicine Code New patient, initial visit
Age 40 through 64 years 99386
Age 65 years and older 99387 Established patient, periodic visit Age 40 through 64 years 99396
Age 65 years and older 99397
Coding and Billing
Preventive Medicine Visits in Conjunction with an E&M Service
What should you do when you find a problem during an otherwise preventive medicine visit?
• Select the appropriate preventive medicine code and the E&M code that best represents the problems addressed.
Example CPT Code Charge Preventive medicine visit Established patient, over 65 years old 99397 $225
Office visit, level 4 99214 $175 The patient will owe the difference if he or she has Medicare and a secondary insurance. 5 – $175 = $50 Medicare allowable for a level 4 visit $87.78 Medicare pays 80% $70.22 Patient or secondary insurance pays
remaining 20% $17.56
Patient total out-of-pocket may be up to $50 + $17.56 = $67.50
Note: Medigap will pay the secondary insurance amount but not the additional charge for the preventive medicine service that is not covered.
• Do not increase the level of the code for the E&M service to account for preventive medicine efforts.
Preventive Services Covered Under the Affordable Care Act CPT CODE(S) (Append Modifier 33 to services that are not inherently reventive to i dicate an ACA service e.g. 99201-99215) HCPCS CODE(S) (Medicare & some commercial payers) Suggested ICD9 CODE(S) (In order of preference) Note: Most private payers expect that these preventive services (counseling, screening and immunizations) occur during the annual preventive exam and may not reimburse separately for these on the same day nor at subsequent visits.
* CMS billing guidelines indicate Physician or Advanced Practice Practitioners may use modifier 25 with modifier EP or modifier TJ for preventive medicine service codes (99381 - 99397 and additional screening codes 99406-99409 and 99420) when reported in conjunction with immunization administrative services (90460-99474). Physician or Advanced Practice Practitioners may submit corrected replacement claims if appropriate.
* Modifier 25 may be used with other non-preventive medicine E/M services when reported in conjunction with immunization administration when the E/M service is significant and separately identifiable. Exception: If a vaccine is billed with the same date of service as code 99211, NCCI edits do not permit the E/M code to be reimbursed. CMS has stated that an E/M code should not be billed in addition to the administration code(s) when the beneficiary presents for vaccine(s) only.
* CMS billing guidelines indicate Physician or Advanced Practice Practitioners may use modifier 25 with modifier EP or modifier TJ for preventive medicine service codes (99381 - 99397 and additional screening codes 99406-99409 and 99420) when reported in conjunction with immunization administrative services (90460-99474). Physician or Advanced Practice Practitioners may submit corrected replacement claims if appropriate.
99381, 99382, 99383, 99384, 99385, 99386, 99387 (Preventive visits for new patients by age)
G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment)
V70.0 (Routine general exam)
99391, 99392, 99393, 99394, 99395, 99396, 99397(Preventive visits for established patients by age)
G0438 (Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit)
V72.31 (Routine gyn exam)
G0439 (Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit)
S0610 (Annual gynecological examination, new patient)
S0612 (Annual gynecological examination, established patient)
S0613 (Annual gynecological examination; clinical breast examination without pelvic evaluation)
EPSDT CPT codes well-child visits STAGE (Age) NEW PATIENT CPT CODE
ESTABLISHED PATIENT CPT CODE
INFANCY (Prenatal – 9 months) 99381 99391
EARLY CHILDHOOD (12 months – 4 years) 99382 99392
MIDDLE CHILDHOOD (5 years – 10 years) 99383 99393
ADOLESCENCE STAGE 1 (11 years – 17 years) 99384 99394
ADOLESCENCE STAGE 2 (18 years – 21 years) 99385 99395
EPSDT CPT codes for sensory screening
SERVICE CPT CODE
VISION 99173
HEARING (Audio) 92551
HEARING (Pure tone-air only) 92552
Adult annual preventive care visits
New patient
CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years
CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years
CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older
Established patient
CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years
CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years
CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older
Adolescent annual preventive care visits
New patient
CPT Code 99382: Initial Preventive Medicine New Patient age 1-4 years
CPT Code 99383: Initial Preventive Medicine New Patient age 5-11 years
CPT Code 99384: Initial Preventive Medicine New Patient age 12-17 years
Established patient
CPT Code 99392: Periodic Preventive Medicine Established Patient age 1-4 years
CPT Code 99393: Periodic Preventive Medicine Established Patient age 5-11 years
CPT Code 99394: Periodic Preventive Medicine Established Patient age 12-17 years
EPSDT codes PLUS Evaluation and Management (E&M) codes PLUS Modifier 25* PLUS
ICD-9 Diagnosis codes 99381–99385 or 99391-99395 The components of the EPSDT visit must be provided and documented. 99203–99215 The presenting problem must be of moderate to high severity. Documentation must support the use of modifier 25. V20.2 or V70.0 must be the primary diagnosis diagnosis code for the visit. Add the diagnosis codes for the presenting problem focused evaluation
*If a patient is evaluated and treated for a problem during the same visit as an EPSDT exam, the problem-oriented exam can be billed along with the EPSDT visit when accompanied by the 25 modifier. Modifier 25 means that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day of the procedure or other service which was provided. In other words, two services were provided on the same day by the same provider, which could have been billed separately if the patient had been seen on two separate dates
Limitations for added procedure code: Procedure codes 96160 and 96161 replace discontinued procedure code 99420 and may be reimbursed for services rendered to clients who are 12 through 18 years of age as follows:
• To NP, CNS, PA, physician, and FQHC providers for services rendered in the office setting. Procedure codes 96160 and 96161 will be denied if billed with the same date of service as procedure codes 99384, 99385, 99394, and 99395.
Providers must use procedure code 96160 or 96161 for the required mental health screening. Procedure codes 96160 and 96161 must be billed with the appropriate medical check-up procedure code. Only one procedure code (96160 or 96161) may be reimbursed once per lifetime.
Limitations for added procedure code: Discontinued procedure code 99420 has been replaced by added procedure codes 96160 and 96161. Procedure codes 96160 and 96161 may be reimbursed as follows:
• For services rendered to clients who are 12 through 18 years of age.
• To Federally Qualified Health Center (FQHC) and THSteps providers for THSteps services rendered in the office setting.
Mental health screening for behavioral, social, and emotional development is required at each THSteps checkup. Mental health screening using one of the validated, standardized mental health screening tools recognized by THSteps is required once for all clients who are 12 through 18 years of age.
A mental health screening must be submitted with procedure code 96160 for a screening tool completed by the adolescent, or procedure code 96161 for a screening tool completed by the parent or caregiver on behalf of the adolescent. When claims with procedure code 96160 or 96161 are submitted for mental health screenings, one of the validated, standardized mental health screening tools recognized by THSteps must be used.
Only one procedure code (96160 or 96161) may be reimbursed for the mental health screening per client per lifetime based on the description of the procedure code and the service rendered. Procedure codes 96160 and 96161 will not be reimbursed for the same client for any date of service. Procedure code 96160 or 96161 must be submitted with the same date of service by the same provider as procedure code 99384, 99385, 99394, or 99395. The client’s medical record must include documentation identifying the tool that was used, the screening results, and any referrals that are made.
EPSDT REQUIREMENTS FOR FLORIDA MMA
The Florida Agency for Health Care Administration (AHCA) requires providers to include the Child Health Check up modifier and referral code that identifies the health screening of a child on the CMS 1500 form and the 837P EDI. portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/Child_Health_Check-UpHB.pdf (starting page 36)
Billing Requirements:
A claim with a procedure code that falls within the procedure code range of 99381-99384 or 99391-99394 must also contain the appropriate referral condition code NU, AV, S2 or ST in Form Item Number 24H shaded for paper on the CMS 1500 form or the SV111 segment with a CRC qualifier for EDI.
A claim submitted with procedure codes 99385 or 99395 must meet the age requirement (ages 18-20), be billed with an EP modifier and contain the appropriate referral condition code NU, AV, S2 or ST.
The EPSDT referral indicator must be present for all codes that meet the FL State requirement of being a Child Health Check up code.
The EPSDT indicator referral condition codes AV, ST, S2 and NU, and Y/N family planning indicator requirements, are documented in the National Uniform Claim Committee (NUCC) billing guide for CMS 1500 and the X12N/005010X222 Professional 837P EDI guides. Please refer to the guides for correct billing requirements.
Know Medicare screening services fully - CPT and covered DX
Summary of Medicare Screening Services
| Possible Procedure/HCPCS Codes | Coverage | Patient Criteria | Patient Financial Responsibility | Provider Criteria | Possible Diagnosis Codes |
| Screening Pelvis Examination | |||||
| G0101 | Every 2 years | Not high risk | 20 % allowable No Part B deductible | None stated | V76.2, V76.47, V76.49, V72.31 |
| Annually | High risk | V15.89 | |||
| Collection of Pap Smear Specimen | |||||
| Q0091 | Every 2 years | Not high risk | 20 % allowable No Part B deductible | None stated | V76.2, V76.47, V76.49, V72.31 |
| Annually | High risk | V15.89 | |||
| Screening Hemoccult | |||||
| 82270 G0328 | Annually | >50 years old | None | None stated | V76.51, V76.41 |
| Screening Mammography | |||||
| 77057, +77052 G0202 | Annually | >40 years old | 20 % allowable No Part B deductible | None stated | V76.12, V76.11 |
| Screening Bone Mass Measurement | |||||
| 77078, 77079, 77080, 77081, 77083, 76977, G0130 | Once every 24 months | Patients at risk | 20% allowable Deductible applies | Test ordered by physician or qualifed non physician practitioner who is treating patient. | Determined by Local Carriers* |
| Initial Preventive Physical Examination (Welcome to Medicare Examination) | |||||
| G0402, G0403, G0404, G0405 | Once | Within first 12 months of Medicare coverage | 20% allowable Deductible waived, but co-insurance provision apply | Test ordered by physician or qualifed non physician practitioner who is treating patient. | V070.0 |
| Diabetes Screening | |||||
| 82947, 82950, 82951 | Twice in 12 month period | Patients at risk | None | None stated | V77.1 |
| Cardiovascular Screening Blood Test | |||||
| 82465, 84478, 83718, 80061 | Every 5 years | All Medicare beneficiaries | None | Test must be ordered by physician and used in management of patient | V81.0, V81.1, V81.2 |
| Tobacco Use Cessation Counseling | |||||
| 99406, 99407 | 2 cessation attempts in 12 month period (1 attempt=up to 4 sessions) | Patient has condition or is receiving treatment that is being adversely affected by tobacco use | 20% allowable Deductible applies | Provided by a physician, physician assistant, nurse practitioner, clinical nurse specialist, qualified psychologist or clinical social worker | Use code indicating patient's condition or treatment affected by tobacco use |
Subscribe to:
Posts (Atom)
Top Medicare billing tips
-
Patient Discharge Status Code - Definition A patient discharge status code is a two-digit code that identifies where the patient is at th...
-
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr... -
REIMBURSEMENT GUIDELINES Global Obstetrical (OB) Care As defined by the American Medical Association (AMA), "the total obstetric pa...
-
procedure code and description 93922 LIMITED BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, (EG, FOR LOW...
-
CPT CODE J3301 - Kenalog-40 Injection Kenalog-40 Injection (triamcinolone acetonide injectable suspension, USP) is a synthetic glucocortic...
-
Procedure code and description 95806 - Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory air...
-
Frequency Limitations: Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonabl...
-
Procedure code and Description 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the...
-
procedure code and description 11042 -Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 square cm ...
-
Procedure Code Changes and Description • Deleted Codes * 49080 - Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic...