Medicare Claims Processing Manual - …

1 Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services Table of Contents (Rev. 1953, 04-28-10) Transmittals for Chapter 18 Crosswalk to Old Manuals 10 - Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines - Coverage Requirements - Pneumococcal Vaccine - Influenza Virus Vaccine - Hepatitis B Vaccine - Billing Requirements - Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Codes - Bills Submitted to FIs/AB MACs - FI/AB MAC Payment for Pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus Vaccines and Their Administration - Special Instructions for Independent and Provider-Based Rural Health Clinics/Federally Qualified Health Center (RHCs/FQHCs) - Bills Submitted to Regional Home Health Intermediaries (RHHIs) - Bills Submitted by Hospices and Payment Procedures for Renal Dialysis Facilities (RDF) - Hepatitis B Vaccine Furnished to ESRD Patients - Claims Submitted to Carriers/AB MACs - Carrier/AB MAC Indicators for the Common Working File (CWF) - Carrier /AB MAC Payment Requirements - Simplified Roster Claims for Mass Immunizers - Roster Claims Submitted to Carriers /AB MACs for Mass Immunization - Centralized Billing for Influenza Virus and Pneumococcal Vaccines to Medicare Carriers - Claims Submitted to FIs/AB MACs for Mass Immunizations of Influenza Virus and Pneumococcal Vaccinations - Simplified Billing for Influenza Virus Vaccine and Pneumococcal Vaccine Services by HHAs - Hospital Inpatient Roster Billing - Electronic Roster Claims - CWF Edits - CWF Edits on FI/AB MAC Claims - CWF Edits on Carrier/AB MAC Claims - CWF A/B Crossover Edits for FI/AB MAC and Carrier/AB MAC Claims - Medicare Summary Notice (MSN) 20 - Mammography Services (Screening and Diagnostic)

2 - Certification of Mammography Facilities - Services Under Arrangements - FDA Certification Data - Using Certification Data in Claims Processing - HCPCS and Diagnosis Codes for Mammography Services - Computer-Aided Detection (CAD) Add-On Codes - CAD Billing Charts - Payment - Payment for Screening Mammography Services Provided Prior to January 1, 2002 - Payment for Screening Mammography Services Provided On or After January 1, 2002 - Outpatient Hospital Mammography Payment Table - Payment for Computer Add-On Diagnostic and Screening Mammograms for FIs and Carriers - Critical Access Hospital Payment - CAH Screening Mammography Payment Table - SNF Mammography Payment Table - Billing Requirements FI/A/B MAC Claims - Rural Health Clinics and Federally Qualified Health Centers - RHC/FQHC Claims With Dates of Service Prior to January 1, 2002 - RHC/FQHC Claims With Dates of Service on or After January 1, 2002 - FI Requirements for Nondigital Screening Mammographies - FI Data for CWF and the Provider Statistical and Reimbursement Report (PS&R)

3 - Billing Requirements-Carrier/B MACs Claims - Part B Carrier claim Record for CWF - Carrier and CWF Edits - Transportation Costs for Mobile Units - Instructions When an Interpretation Results in Additional Films - Mammograms Performed With New Technologies - Beneficiary and Provider Notices - MSN Messages - Remittance Advice Messages 30 - Screening Pap Smears - Pap Smears From January 1, 1998, Through June 30 2001 - Pap Smears On and After July 1, 2001 - Deductible and Coinsurance - Payment Method - Payment Method for RHCs and FQHCs - HCPCS Codes for Billing - Diagnoses Codes - Type of Bill and Revenue Codes for Form CMS-1450 - MSN Messages - Remittance Advice Codes 40 - Screening Pelvic Examinations - Screening Pelvic Examinations From January 1, 1998, Through June 30 2001 - Screening Pelvic Examinations on and After July 1, 2001 - Deductible and Coinsurance Diagnosis Codes Payment Method Revenue Code and HCPCS Codes for Billing MSN Messages Remittance Advice Codes 50 - Prostate Cancer Screening Tests and Procedures - Definitions - Deductible and Coinsurance - Payment Method - FIs and Carriers - Correct Coding Requirements for Carrier Claims - HCPCS, Revenue, and Type of Service Codes - Diagnosis Coding - Calculating Frequency - MSN Messages - Remittance Advice Notices 60 - Colorectal Cancer Screening - Payment Deductible and Coinsurance - HCPCS Codes, Frequency Requirements, and Age Requirements (If Applicable) - Common Working Files (CWF) Edits - Ambulatory Surgical Center (ASC)

4 Facility Fee - Determining High Risk for Developing Colorectal Cancer - Determining Frequency Standards - Noncovered Services - Billing Requirements for Claims Submitted to FIs - MSN Messages - Remittance Advice Notices 70 - Glaucoma Screening Services - Claims Submission Requirements and Applicable HCPCS Codes - HCPCS and Diagnosis Coding - Additional Coding Applicable to Claims Submitted to FIs - Special Billing Instructions for RHCs and FQHCs - Edits - Payment Methodology - Determining the 11-Month Period - Remittance Advice Notices - MSN Messages 80 Initial Preventive Physical Examination (IPPE) HCPCS Coding for the IPPE Carrier Billing Requirements Fiscal Intermediary Billing Requirements RHC/FQHCs Special Billing Instructions Indian Health Services (IHS) Hospitals Special Billing Instructions - OPPS Hospital Billing Coinsurance and Deductible Medicare Summary Notices (MSNs) Remittance Advice Remark Codes Claims Adjustment Reason Codes Advance Beneficiary Notice (ABN)

5 As Applied to the IPPE 90 Diabetes Screening HCPCS Coding for Diabetes Screening Carrier Billing Requirements Modifier Requirements for Pre-diabetes Fiscal Intermediary Billing Requirements Modifier Requirements for Pre-diabetes Diagnosis Code Reporting Medicare Summary Notices Remittance Advice Remark Codes - Claims Adjustment Reason Codes 100 Cardiovascular Disease Screening - HCPCS Coding for Cardiovascular Screening - Carrier Billing Requirements - Fiscal Intermediary Billing Requirements - Diagnosis Code Reporting - Medicare Summary Notices - Remittance Advice Remark Codes - Claims Adjustment Reason Codes 110 - Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) - Definitions - Coverage - Payment - Deductible and Coinsurance - HCPCS Code Advanced Beneficiary Notice - RHCs/FQHCs Special Billing Instructions 120 - Diabetes Self Management Training (DSMT) Services - Coding and Payment of DSMT Services - Bill Processing Requirements - Special Processing Instructions for Billing Frequency Requirements Advance Beneficiary Notice (ABN) Requirements - RHCs/FQHCs Special Billing Instructions - Duplicate Edits 130 Healthcare Common Procedure Coding System (HCPCS) for HIV Screening Tests Billing Requirements Payment Method Types of Bill (TOBs) and Revenue Codes Diagnosis Code Reporting Medicare Summary Notice (MSN) and claim Adjustment Reason Codes (CARC) 150 Counseling to Prevent Tobacco Use HCPCS and Diagnosis Coding Carrier Billing Requirements Medicare Summary Notices (MSNs)

6 , Remitance and Advice Remark Codes (RARC), Claims Adjustment Reason Codes (CARC), and Group Code Common Working File (CWF) 10 - Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines (Rev. 1586, Issued: 09-05-08, Effective: 10-06-08, Implementation: 10-06-08) For Carriers/AB MACs, Part B of Medicare pays 100 percent of the Medicare allowed amount for pneumococcal vaccines and influenza virus vaccines and their administration. Part B deductible and coinsurance do not apply for pneumococcal and influenza virus vaccine. Part B of Medicare also covers the hepatitis B vaccine and its administration. Part B deductible and coinsurance do apply for hepatitis B vaccine. State laws governing who may administer pneumococcal and influenza virus vaccinations and how the vaccines may be transported vary widely. Medicare contractors should instruct physicians, suppliers, and providers to become familiar with State regulations for all vaccines in the areas where they will be immunizing.

7 - Coverage Requirements (Rev. 1586, Issued: 09-05-08, Effective: 10-06-08, Implementation: 10-06-08) Pneumococcal vaccine, influenza virus vaccine, and hepatitis B vaccine and their administration are covered only under Medicare Part B, regardless of the setting in which they are furnished, even when provided to an inpatient during a hospital stay covered under Part A. See Pub. 100-02, Medicare Benefit Policy Manual , chapter 15, for additional coverage requirements for pneumococcal vaccine, hepatitis B vaccine, and influenza virus vaccine. - Pneumococcal Vaccine (Rev. 1586, Issued: 09-05-08, Effective: 10-06-08, Implementation: 10-06-08) Effective for services furnished on or after July 1, 2000, Medicare does not require for coverage purposes, that a doctor of medicine or osteopathy order the pneumococcal vaccine and its administration. Therefore, the beneficiary may receive the vaccine upon request without a physician s order and without physician supervision.

8 See Pub. 100-02, Medicare Benefit Policy Manual , chapter 15, section for additional coverage requirements for pneumococcal vaccine. A. Frequency of Pneumococcal Vaccinations Typically, the pneumococcal vaccine is administered once in a lifetime. Claims are paid for beneficiaries who are at high risk of pneumococcal disease and have not received the pneumococcal vaccine within the last 5 years or are revaccinated because they are unsure of their vaccination status. An initial pneumococcal vaccination may be administered only to persons at high risk (see below) of pneumococcal disease. Revaccination may be administered only to persons at highest risk of serious pneumococcal infection and those likely to have a rapid decline in pneumococcal antibody levels, provided that at least 5 years have passed since receipt of a previous dose of pneumococcal vaccine. B. High Risk of Pneumococcal Disease Persons at high risk for whom an initial vaccine may be administered include: !

9 All people age 65 and older; ! Immunocompetent adults who are at increased risk of pneumococcal disease or its complications because of chronic illness ( , cardiovascular disease, pulmonary disease, diabetes mellitus, alcoholism, cirrhosis, or cerebrospinal fluid leaks); and ! Individuals with compromised immune systems ( , splenic dysfunction or anatomic asplenia, Hodgkin s disease, lymphoma, multiple myeloma, chronic renal failure, Human Immunodeficiency Virus (HIV) infection, nephrotic syndrome, sickle cell disease, or organ transplantation). Persons at highest risk and those most likely to have rapid declines in antibody levels are those for whom revaccination may be appropriate. This group includes persons with functional or anatomic asplenia ( , sickle cell disease, splenectomy), HIV infection, leukemia, lymphoma, Hodgkin s disease, multiple myeloma, generalized malignancy chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression such as organ or bone marrow transplantation, and those receiving immunosuppressive chemotherapy.

10 Routine revaccinations of people age 65 or older that are not at highest risk are not appropriate. Those administering the vaccine should not require the patient to present an immunization record prior to administering the pneumococcal vaccine, nor should they feel compelled to review the patient s complete medical record if it is not available. Instead, if the patient is competent, it is acceptable for them to rely on the patient s verbal history to determine prior vaccination status. If the patient is uncertain about their vaccination history in the past 5 years, the vaccine should be given. However, if the patient is certain he/she was vaccinated in the last 5 years, the vaccine should not be given. If the patient is certain that the vaccine was given and that more than 5 years have passed since receipt of the previous dose, revaccination is not appropriate unless the patient is at highest risk. - Influenza Virus Vaccine (Rev.)