Medicare Claims Processing Manual

1 Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services Table of Contents (Rev. 33, 11-28-03) crosswalk to Old Manuals 10 - Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines - Coverage Requirements - Pneumococcal Pneumonia Vaccine (PPV) - Influenza Virus Vaccine - Hepatitis B Vaccine - Billing Requirements - Healthcare Common Procedural Coding System (HCPCS) and Diagnosis Codes - Bills Submitted to FIs - FI Payment for Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines - 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 - Carrier Indicators for the Common Working File (CWF) - Carrier Payment Requirements - Simplified Roster Claims for Mass Immunizers - Roster Claims Submitted to Carriers for Mass Immunization - Centralized Billing for Flu and Pneumococcal (PPV) Vaccines to Medicare Carriers - Claims Submitted to FIs for Mass Immunizations of Influenza and PPV - Simplified Billing for Influenza Virus Vaccine and PPV Services by HHAs - Hospital Inpatient Roster Billing - Electronic Roster Claims - CWF Edits - CWF Edits on FI Claims - CWF Edits on Carrier Claims - CWF A/B Crossover Edits for FI and Carrier Claims - Medicare Summary Notice (MSN) 20 - Screening Mammography Services - Mammography Quality Standards Act (MQSA)

2 - Under Arrangements MSQA File - HCPCS and Diagnosis Codes for Mammography Services - Computer-Aided Detection (CAD) Add-On Codes - Payment - Payment for Services Prior to January 1, 2002 - Payment for Services On and After January 1, 2002 - Outpatient Hospital Mammography Payment Table - Payment for Computer Add-On Diagnostic Mammograms - Critical Access Hospital Payment - CAH Mammography Payment Table - SNF Mammography Payment Table - Billing Requirements - FI 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) - Carrier Processing Requirements - Part B Carrier claim Record for CWF - 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.

3 2001 - Deductible and Coinsurance - 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 - 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 - 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 10 - Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines (Rev.)

4 1, 10-01-03) , B3-4480, , A3-3110 (partial), A3-3157 (partial), A3-3192 (partial), , RHC-614, , B, , , B, , RHC-404 Part B of Medicare pays 100 percent for pneumococcal pneumonia vaccines (PPV) and influenza virus vaccines and their administration. For carriers, Part B of Medicare pays 100 percent of the Medicare allowed amount for pneumococcal pneumonia vaccines (PPV) and influenza virus vaccines and their administration. Part B deductible and coinsurance do not apply for PPV 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. See the chart in Chapter 16. State laws governing who may administer PPV and influenza virus vaccinations and how the vaccines may be transported vary widely. Intermediaries (FIs) and carriers should instruct physicians, suppliers, and providers to become familiar with State regulations for all vaccines in the areas where they will be immunizing.

5 - Coverage Requirements (Rev. 1, 10-01-03) , B3-4480, , 3110, 3157, 3192, , RHC-614, , B, , , B, , RHC-404 Pneumococcal vaccine (PPV), 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 the Medicare Benefit Policy Manual , Chapter 15, for additional coverage requirements for PPV, hepatitis B vaccine, and Influenza Virus vaccine. - Pneumococcal Pneumonia Vaccine (PPV) (Rev. 1, 10-01-03) 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 PPV vaccine and its administration. Therefore, the beneficiary may receive the vaccine upon request without a physician s order and without physician supervision.

6 See the Medicare Benefit Policy Manual , Chapter 15, for additional coverage requirements for PPV. A - Frequency of PPV Vaccinations Typically, PPV is administered once in a lifetime. Claims are paid for beneficiaries who are at high risk of pneumococcal disease and have not received PPV within the last five years or are revaccinated because they are unsure of their vaccination status. An initial PPV 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 five 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: 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).

7 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. 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.

8 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 five years, the vaccine should be given. However, if the patient is certain he/she was vaccinated in the last five years, the vaccine should not be given. If the patient is certain that the vaccine was given and that more than five years have passed since receipt of the previous dose, revaccination is not appropriate unless the patient is at highest risk. - Influenza Virus Vaccine (Rev. 1, 10-01-03) Effective for services furnished on or after May 1, 1993, the influenza virus vaccine and its administration is covered when furnished in compliance with any applicable State law. Typically, this vaccine is administered once a year in the fall or winter.

9 Medicare does not require for coverage purposes that a doctor of medicine or osteopathy order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician s order and without physician supervision. Typically, one influenza vaccination is allowable per flu season. Contractors edit to identify more than one influenza virus vaccine in a 12-month period, and determine medical necessity of services failing the edit. Since there is no yearly limit, contractors determine whether such services are reasonable and necessary ( , a patient receives an influenza injection in January for the current flu season and is vaccinated again in November of the same year for the next flu season) and allow payment if appropriate. See the Medicare Benefit Policy Manual , Chapter 15, for additional coverage requirements for Influenza Virus vaccines.

10 - Hepatitis B Vaccine (Rev. 1, 10-01-03) Effective for services furnished on or after September 1, 1984, the hepatitis B vaccine and its administration is covered if it is ordered by a doctor of medicine or osteopathy and is available to Medicare beneficiaries who are at high or intermediate risk of contracting hepatitis B, , exposed to hepatitis B. See the Medicare Benefit Policy Manual , Chapter 15, for additional coverage requirements for hepatitis B vaccines to high risk and intermediate risk groups. - Billing Requirements (Rev. 1, 10-01-03) , , (partial), , RHC-614, , , , , HHA 219, A - Edits Not Applicable to PPV or Influenza Virus Vaccine Bills and Their Administration The CWF and shared systems bypass all Medicare Secondary Payer (MSP) utilization edits in Common Working File (CWF) on all Claims when the only service provided is PPV or influenza virus vaccine and/or their administration.