Medicare Claims Processing Manual

1 Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services Table of Contents (Rev. 11092, 10-29-21) Transmittals for Chapter 18 1 - Medicare Preventive and Screening Services - Definition of Preventive Services - Table of Preventive and Screening Services - Waiver of Cost Sharing Requirements of Coinsurance, Copayment and Deductible for Furnished Preventive Services Available in Medicare 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 - Claims Submitted to MACs Using Institutional Formats - Payment for pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus Vaccines and Their Administration on Institutional Claims - Special Instructions for Independent and Provider-Based Rural Health Clinics/Federally Qualified Health Center (RHCs/FQHCs)

2 - Institutional Claims Submitted by Home Health Agencies and Hospices - Payment Procedures for Renal Dialysis Facilities (RDF) - Hepatitis B Vaccine Furnished to ESRD Patients - Claims Submitted to A/B MACs (B) - A/B MACs (B) Indicators for the Common Working File (CWF) - A/B MACs (B) Payment Requirements - Simplified Roster Claims for Mass Immunizers - Roster Claims Submitted to A/B MACs (B) for Mass Immunization - Centralized Billing for Influenza Virus and pneumococcal Vaccines to A/B MACs (B) - Claims Submitted to A/B MACs (A) 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 A/B MAC (A) Claims - CWF Edits on A/B MAC (B) Claims - CWF Crossover Edits for A/B MAC (B) Claims - Medicare Summary Notice (MSN) 20 - Mammography Services (Screening and Diagnostic) - Certification of Mammography Facilities - Services Under Arrangements - FDA Certification Data - Using Certification Data in Claims Processing - HCPCS and Diagnosis Codes for Mammography Services Digital Breast Tomosynthesis - CAD Billing Charts - Digital Breast Tomosynthesis - claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages - Payment - Payment for Screening Mammography Services Provided On and After January 1, 2002 - Outpatient Hospital Mammography Payment Table - Critical Access Hospital Payment - CAH Screening Mammography Payment Table - SNF Mammography Payment Independent Diagnostic Testing Facility (IDTF)

3 Mammography Payment - 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 A/B MACs (A) and (B) - Critical Access Hospital Payment - CAH Screening Mammography Payment Table - SNF Mammography Payment Table - Billing Requirements - A/B MAC (A) 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 - A/B MAC (A) Requirements for Nondigital Screening Mammographies - A/B MAC (A) Data for CWF and the Provider Statistical and Reimbursement Report (PS&R) - Billing Requirements-A/B MAC (B) Claims - A/B MAC (B) claim Record for CWF - A/B MAC (B) 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 - Screening for Cervical Cancer with Human Papillomavirus Testing - Deductible and Coinsurance - Payment Method - Payment Method for RHCs and FQHCs - Screening Pap Smears: Healthcare Common Procedure Coding System HCPCS Codes for Billing - Screening Pap Smears.

4 Diagnoses Codes - TOB 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 - A/B MACs (A) and (B) - Correct Coding Requirements for A/B MAC (B) 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) Facility Fee - Determining High Risk for Developing Colorectal Cancer - D etermining Frequency Standards - Noncovered Services - Billing Requirements for Claims Submitted to A/B MACs (A) - Medicare Summary Notice (MSN) Messages - Remittance Advice Codes 70 - Glaucoma Screening Services - Claims Submission Requirements and Applicable HCPCS Codes - HCPCS and Diagnosis Coding - Additional Coding Applicable to Claims Submitted to A/B MACs (A) - 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) - Healthcare Common Procedure Coding System (HCPCS) Coding for the IPPE A/B Medicare Administrative Contractor (MAC) (B) Billing Requirements - A/B MAC (A) Billing Requirements - Rural Health Clinic (RHC)

5 /Federally Qualified Health Center (FQHC) Special Billing Instructions - Indian Health Services (IHS) Hospitals Special Billing Instructions - Outpatient Prospective Payment System (OPPS) Hospital Billing - Coinsurance and Deductible - Medicare Summary Notices (MSNs) - Remittance Advice Remark Codes - Claims Adjustment Reason Codes - Advance Beneficiary Notice (ABN) as Applied to the IPPE 90 - Diabetes Screening - HCPCS Coding for Diabetes Screening - A/B MAC (B) Billing Requirements - Modifier Requirements for Pre-diabetes - A/B MAC (A) 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 - A/B MAC (B) Billing Requirements - A/B MAC (A) 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 - Human Immunodeficiency Virus (HIV) Screening Tests - Healthcare Common Procedure Coding System (HCPCS) for HIV Screening Tests - Billing Requirements - Payment Method - Types of Bill (TOBs)

6 And Revenue Codes - Diagnosis Code Reporting - Medicare Summary Notice (MSN) and claim Adjustment Reason Codes (CARCs) 140 - Annual Wellness Visit (AWV) - Healthcare Common Procedure Coding System (HCPCS) Coding for the AWV - A/B MAC (B) Billing Requirements - A/B MAC (A) Billing Requirements - Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC) Special Billing Instructions - Coinsurance and Deductible - Common Working File (CWF) Edits - Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Advance Beneficiary Notices (ABNs) - Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV) 150 - Counseling to Prevent Tobacco Use - Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Coding - A/B MAC (B) Billing Requirements - A/B MAC (A) Billing Requirements - Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Group Codes - Common Working File (CWF) 160 - Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD) Furnished on or After November 8, 2011 - Coding Requirements for IBT for CVD Furnished on or After November 8, 2011 - Claims Processing Requirements for IBT for CVD Furnished on or After November 8, 2011 - Correct Place of Service (POS) Codes for IBT for CVD on Professional Claims - Provider Specialty Edits for IBT for CVD on Professional Claims Correct Types of Bill (TOB) for IBT for CVD on Institutional Claims Frequency Edits for IBT for CVD Claims - Common Working File (CWF) Edits for IBT for CVD Claims 170 - Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs - Healthcare Common Procedure Coding System (HCPCS)

7 Codes for Screening for STIs and HIBC to Prevent STIs - Diagnosis Code Reporting - Billing Requirements - Types of Bill (TOBs) and Revenue Codes - Payment Method - Specialty Codes and Place of Service (POS) 180 - Alcohol Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse - Policy - Institutional Billing Requirements - Professional Billing Requirements - claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes and Medicare Summary Notice Messages - Common Working File (CWF) Requirements 190 - Screening for Depression in Adults (Effective October 14, 2011) - A/B MAC (B) Billing Requirements - Frequency - Place of Service (POS) - Common Working File (CWF) Edits - Professional Billing Requirements - Institutional Billing Requirements - CARCs, RARCs, Group Codes, and MSN Messages 200 - Intensive Behavioral Therapy for Obesity (Effective November 29, 2011) - Policy - Institutional Billing Requirements - Professional Billing Requirements - claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages - Common Working File (CWF) Edits 210 - Screening for Hepatitis C Virus (HCV) - Institutional Billing Requirements - Professional Billing Requirements - claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages - Common Working File (CWF) Edits 220 - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) - Healthcare Common Procedure Coding System (HCPCS) Codes - Institutional Billing Requirements - Deductible and Coinsurance - claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages - Common Working File (CWF)

8 Edits 230 Screening for Hepatitis B Virus (HBV) Institutional Billing Requirements Professional Billing Requirements Diagnosis Code Reporting Requirements claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages 240 - Prolonged Preventive Services Codes Table of Preventive and Screening Services (Rev. 11092; Issued:10-29-21; Effective:10-01-21; Implementation: 04-04-22) Service CPT/ HCPCS Long Descriptor USPSTF Rating Deductible Initial Preventive Physical Examination, IPPE G0402 Initial preventive physical examination; face to face visits, services limited to new beneficiary during the first 12 months of Medicare enrollment *Not Rated WAIVED G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report Not Waived G0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination Not Waived G0405 Electrocardiogram, routine ECG with 12 leads.

9 Interpretation and report only, performed as a screening for the initial preventive physical examination Not Waived Service CPT/ HCPCS Long Descriptor USPSTF Rating Deductible Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) services furnished prior to January 1, 2017 G0389 Ultrasound, B-scan and /or real time with image documentation; for abdominal aortic aneurysm (AAA) ultrasound screening B WAIVED Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) services furnished on or after January 1, 2017 76706 Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) B WAIVED Cardiovascular Disease Screening 80061 Lipid panel A WAIVED 82465 Cholesterol, serum or whole blood, total WAIVED 83718 Lipoprotein, direct measurement; high density cholesterol (hdl cholesterol) WAIVED 84478 Triglycerides WAIVED Diabetes Screening Tests 82947 Glucose; quantitative, blood (except reagent strip) B WAIVED 82950 Glucose; post glucose dose (includes glucose) WAIVED Service CPT/ HCPCS Long Descriptor USPSTF Rating Deductible 82951 Glucose; tolerance test (gtt), three specimens (includes glucose) *Not Rated WAIVED Diabetes Self- Management Training Services (DSMT) G0108 Diabetes outpatient self- management training services, individual, per 30 minutes *Not Rated Not Waived G0109 Diabetes outpatient self- management training services, group session (2 or more), per 30 minutes Not Waived Medical Nutrition Therapy (MNT) Services 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face wi