coders are unstoppable!! · 1 coders are unstoppable!! are you sure you can bill preventive...

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Coders Are Unstoppable!!

Are You Sure You Can Bill Preventive Services?

Presented by Pat Champion, CPC, CPC-I

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Let’s Take a Look

• Review Initial Preventive Physical Examination (IPPE)

• Understand the difference in the IPPE and the Annual Well Visit (AWV) along with the Subsequent Annual Well Visit

• Discuss other screening services and education for self management recognized by Medicare

• Review Medicare Immunizations

“Welcome to Medicare” Exam (IPPE)

• Once in a lifetime exam

• Covered within first 12 months ofCovered within first 12 months of obtaining Part B– Height, weight and body mass index

– Referrals for further diagnostic testing

– Blood pressure

Education counseling and health risk– Education, counseling, and health risk assessment

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Welcome to MedicareCode Definition

G0402“Welcome to Medicare” – Initial Preventive Physical ExamElectrocardiogram routine ECG w/12

G0403Electrocardiogram, routine ECG w/12 leads; screening for the initial preventative PE

G0404…; tracing only, without interpretation and report

G0405 …; interpretation and report only

G0403 G0404 G0405 b bill d i dditi t G0402G0403, G0404, G0405 can be billed in addition to G0402. EKG no longer a required part of IPPE.No specific diagnosis (ICD-9) is required.Co-insurance, co-pay and/or deductible waived only for G0402.

Annual Wellness Visit (AWV)• Once in a lifetime exam including

Personalized Prevention Plan Services (PPPS)Services (PPPS)

• Person Covered – One who is no longer within 12 months

after the effective date of first Medicare Part B coverage

– One who has not received either an initial preventive physical exam or an AWV within the past 12 months

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AWV Includes

• Establish individual’s medical/family historyy

• Establish list of current providers and suppliers regularly involved in providing medical care

• Measure height, weight, BMI, BP and h iothers as appropriate

• Detection of any cognitive impairment

AWV cont.

• Review of individual’s potential for depressionp– Including current or past experiences

• Review functional ability and level of safety based on direct observation or screening questions/questionnaire

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AWV cont.

• Establish a written screening schedule for the individual, such as a checklist for the next 5-10 years, as appropriate

• Patient’s health status

• Screening History

• Age-appropriate preventive servicesg pp p p

AWV cont.

• Establish list of risk factors and conditions and list of treatment options and their associated risks andoptions and their associated risks and benefits– Furnish personalized health advice and

a referral, as appropriate • Health education

• Preventive counseling services

• Programs aimed at reducing identified risk factors and improving self-management

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AWV cont.

• Community-based lifestyle interventions to reduce health risks and promote self management andand promote self-management and wellness– Weight loss

– Physical activity

– Smoking cessation

– Fall prevention

– Nutrition

AWV cont.

• Any other element(s) determined appropriate by the Secretary of H l h d H S i h hHealth and Human Services through the National Coverage Determination (NCD) process

• Not subject to “incident-to”

• Who may perform?• Who may perform?– Doctor of medicine

– Doctor of osteopathy

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AWV Performed By

– Nurse practitioner

– Physician assistant

– Clinical nurse specialist

– Health professional, which includes:• Health educator

• Registered dietitian

• Nutrition professionalp

• Team of such medical professionals who are working under the direct supervision of a physician

Subsequent Wellness Visit• Performed 11 months after AWV &

includes– Update to medical/family history– Update to medical/family history

– Measurements of weight (or waist circumference), blood pressure and routine measurements as deemed appropriate

– Update to list of current medical– Update to list of current medical providers/suppliers

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SWV

– Detection of any cognitive impairment

– Update to written screening schedule

– Update to list of risk factors

– Furnish appropriate health advice and referral as appropriate

Annual & Subsequent Wellness Visit

HCPCS Code Description

G0438 Annual wellness visit, includes Personalized Prevention Plan of Service (PPPS), first visit

G0439 Annual wellness visit, includes PPPS, subsequent visit

No specific diagnosis (ICD-9) is required.Co-insurance, co-pay and/or deductible waived.When a significant, separately identifiable medically necessary E/M service in addition to the AWV, use 99201-99215 with modifier 25; however, co-pay, deductible, co-; , p y, ,insurance required for E/M service.

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AWV Health Risk Assessment

• Intended to be a self-reportedassessment

• Completed prior to or aspart of AWV

• May include some biometrics obtained by providerobtained by provider

• Helps develop a prevention plan

HRA Requirements

1. Collects self reported information about beneficiaryy

2. Can be administered independently by beneficiary or by health professional prior to or as part of AWV

3 Sh ld b i i 5th 6th d3. Should be written in 5th or 6th grade literacy level and in plain language

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AWV HRA cont.

4. Should be linguistically, age, gender and culturally appropriate for patient

5 Sh ld li ith5. Should ensure compliance with current science related to health promotion and disease prevention

– Take advantage of anticipated advances in new technology

– HRA and delivery systems reviewed no less than every 2 years

AWV HRA Information Addressed• Demographic Data Collected

– Age, gender, race, and ethnicity

S lf A t• Self Assessment– Health status, frailty, physical

functioning

• Biometric Assessments– Height, weight, body mass index (BMI),Height, weight, body mass index (BMI),

systolic/diastolic blood pressure, blood lipids (HDL/LDL and total cholesterol, triglycerides), blood glucose

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AWA HRA cont.

• Psychosocial Risks– Depression/life satisfaction, p ,

stress/anger, loneliness/social isolation, pain/fatigue

• Behavioral Risks

• Tobacco use, physical activity, nutrition and oral health alcoholnutrition and oral health, alcohol consumption, sexual practices, motor vehicle safety (seat belt use), home safety

AWV HRA Greater than 65 year-old

• Memory– Cognition assessment, routine g ,

measures of vision and hearing - not part of HRA but AWV

• Activities of Daily Living (ADLs)– Dressing, feeding, toileting, grooming,

physical ambulation includingphysical ambulation, including balance/risk of falls, and bathing

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AWV HRA Greater than 65 year-old

• Instrumental Activities of Daily Living (IADLs)( )• Shopping, food preparation, using the

telephone, housekeeping, laundry, mode of transportation, responsibility for own mediations, and ability to handle finances

AWV HRA cont.

• Interim guidance published by CDC on the development of a health risk passessment tool

• http://www.cms.gov/coveragegeninfo/downloads/healthriskassessmentsCDCfi l dfCfinal.pdf

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HRA Delivery

• Accommodations for individuals with physical, sensory, or cognitive p y y glimitations, low vision or blindness alternative formats such as large print or Braille or audio administration

HRA Delivery cont.

• Available in patient’s preferred language

• Allow access to and use of information and data by individuals with disabilities

• Web-based – preferably via Internet so physician can communicate withso physician can communicate with Electronic Medical Record (EMR) or Personal Health Record (PHR) systems or both

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HRA Delivery cont.

• Interactive telephonic– For patients with physical disabilities, p p y ,

such as blindness or deafness

• Paper based– Used where neither EMR nor Internet

access availableaccess available

Modifiers

• EKG– 93000, 93005, 93010, 93040-93042 , , ,

overridden with modifier 59

• Medical nutrition therapy (MNT)– 97802-97804 cannot be overridden

• Prostate screening – G0102 and reassessment and

subsequent MNT G0270 cannot be overridden

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Screening Services

• Medicare provides coverage for most types of screenings on a yearly basis

• While most screening services do not require prescriptions or referrals by a physician or qualified non-physician practitioner (i.e., clinical nurse specialist, nurse midwife, nurse practitioner, or

h i i i t t) t b d thphysician assistant) to be covered, there are a few exceptions

Abdominal Aortic Aneurysm Screening G0389

• One-time ultrasound screening for at risk beneficiaries as part of IPPE

• Risk factors– Family history of abdominal aortic aneurysms

– Man age 65-75 who has smoked more than 100 cigarettes

• Co-insurance, co-pay and/or deductible i dwaived

• ICD-9 code: No specific diagnosis required

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Bone Mass Measurement G0130, 77078, 77079, 77080, 77081, 77083, 76977

Covered if doctor determines patient is at risk– Every 2 years (more often if medically necessary)

Risk factors– Age 50 or older– Being a woman– Being small and thin– Have a low calcium diet

Ded ctible and coins rance appl Deductible and coinsurance apply One measurement every 24 months

More frequently if medically necessary

Cardiovascular Screening• Medicare will cover these tests every five years• Includes the following tests

– Cholesterol, serum or whole blood, total (82465)

– Lipoprotein direct measurement HDL cholesterol (63718)Lipoprotein, direct measurement, HDL cholesterol (63718)

– Triglycerides (84478)

– Lipid panel (80061)

• Diagnosis should reflect the screening nature– V81.0 : Special screening for cardiovascular disease, ischemic

heart disease

– V81.1 : Special screening for cardiovascular disease, hypertensionyp

– V81.2 : Special screening for cardiovascular disease, other

• Co-insurance, co-pay and/or deductible waived

• Must be ordered by physician

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Colorectal Cancer Screening• Helps find precancerous growths

– Helps prevent or find cancer early

• One or more of the following tests may be• One or more of the following tests may be covered– Fecal Occult Blood Test

– If any below are performed as screening but become diagnostic, append modifier PT

– Flexible Sigmoidoscopyg py

– Colonoscopy

– Barium Enema

Colorectal Cancer ScreeningsTest and Requirements Covered Once Every…

Beneficiary Pays

Fecal Occult Blood Test G0328/82270 w/V76.51Age 50 or older

12 months No deductible or copayment for this test

Flexible Sigmoidoscopy 4 years or once every 10 No deductible orFlexible Sigmoidoscopy G0104 w/V76.51Age 50 or older

4 years or once every 10 years after having a screening colonoscopy

No deductible or copayment for this test

Colonoscopy G0105 (high risk)G0121 (not high risk)w/V76.51No minimum age

24 months at high risk; every 10 years not at high risk

No deductible or copayment for this test.

Barium Enema G0106 48 months (high risk Pay 20% of the Medicare‐(alternative to G0104) if not high riskG0106 if high‐risk w/ V76.51Age 50 or older

every 24 months) when used instead of a sigmoidoscopy or colonoscopy

approved amount for the doctor’s services. In a hospital outpatient setting patient pays a copayment.

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Diabetes Screening Tests• Testing for people meeting risk factor

requirementsi h di b 1– without pre-diabetes: 1 per year

– with pre-diabetes: 2 per year

• Risk Factors: – Hypertension

– Previous elevated impaired fasting glucose or glucose intoleranceglucose intolerance

– Obesity

– Dyslipidemia

Diabetes Screening Tests• Risk Factors include two of the following

– Overweight

– Family history of diabetes

– Age 65 or older

– History of gestational diabetes mellitus, or delivery of a baby weighing greater than nine pounds

• Includes fasting blood glucose test

• Can be performed up to twice in a 12-month periodmonth period


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Diabetes Screening Tests

• 82947 Glucose; quantitative, blood (except reagent strip)

82950 Glucose; post glucose dose (includes• 82950 Glucose; post glucose dose (includes glucose)

• 83951 Glucose; tolerance test (GTT), three specimens (includes glucose)

• ICD-9– V77.1 Special screening for Diabetes Mellitus

*NOTE Cl i b itt d f di b t i t t h th*NOTE: Claims submitted for a diabetes screening test where the beneficiary meets the definition of pre-diabetes should report the HCPCS code with modifier TS.

Covered Diabetes Services

• People with Diabetes can receive– Self-management trainingg g

– Medical nutrition therapy

– Special eye exams

– Hemoglobin A1c tests

• Co-insurance, co-pay and/or d d ibl i ddeductible waived

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Diabetes Self-Management Training (DSMT)

• Coverage for beneficiaries– Recently diagnosed with diabetesy g

– At risk for complications

– Previously diagnosed but new to Medicare

Diabetes Self-Management Training (DSMT)

• G0108 DSMT, individual session, per 30 minutes

• G0109 DSMT, group session, per 30 minutesICD 9 V77 1– ICD-9 = V77.1

– Report “TS” (follow-up service) for diabetes screening where the beneficiary meets the definition of pre-diabetes

• Must exhibit risk for complications from diabetes, recently diagnosed, or previously diagnosed

• Up to 10 hours within continuous 12 months• Up to 10 hours within continuous 12 months

• Up to 2 hours in subsequent years

• Co-insurance, co-pay and/or deductible apply

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Covered Diabetes Supplies• Blood sugar testing supplies

– Insulin and related supplies• Insulin pumps• Insulin pumps

• Special foot care

• Therapeutic shoes


• Medicare Coverage of Diabetes Supplies & Services (CMS Product No. 11022)

Glaucoma Screening

• G0117 By an optometrist or ophthalmologist

• G0118 Under the direct supervision of an optometrist or ophthalmologistoptometrist or ophthalmologist

• Covered once every 12 months if at high risk


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HIV Screening• Medicare covers HIV screening

– Pregnant women– People at increased risk for the infection– Anyone who asks for the test

• Covered once every 12 months • Covered up to 3 times during a pregnancy• Co-insurance, co-pay and/or deductible

waived

• HCPCS codes G0432, G0433, G0435

• Diagnosis– V73.89 & V69.8 or V73.89

Pap Test and Pelvic Exam with Clinical Breast Exam

• Screening Pelvic & Breast Exam– G0101 after 7 bullets of 11 are documented

ICD 9 V76 2 V76 47 V76 49 V15 89 V72 31– ICD-9 = V76.2, V76.47, V76.49, V15.89, V72.31

• Screening Pap Tests– Q0091 Obtaining, preparing & conveyance of cervical or

vaginal smear to lab

– ICD-9 same as above

• Covered for all women with Medicare– Once every 24 months

– Once every 12 months• At high risk for cervical or vaginal cancer

• Childbearing age and abnormal Pap test in the past 36 months

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Screening Pelvic Exam G0101

• Inspection & palpation of breasts for masses or lumps, tenderness, psymmetry of nipple discharge

• Digital rectal examination including for sphincter tone, presence of hemorrhoids, and rectal masses

Pelvic Exam With or Without Specimen Collection for Smears and Cultures

• External genitalia

• Urethral meatus

• Urethra

• Bladder

• Vagina

• Cervix

Ut• Uterus

• Adnexa/parametria

• Anus & perineum

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Screening Mammogram77052, 77057, G0202

• Covered for all women with Medicare– One baseline mammogram age 35 to 39g g

– Once a year starting at age 40

• ICD-9 = V76.11 or V76.12


Diagnostic Mammogram

• Used when there are clinical findings– On physical examp y

– Abnormal screening mammogram

• Medicare covers as many as needed– Also covered for men

• Different payment rates if diagnostic mammogram

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Prostate Cancer Screening

• Covered for all men with Medicare– Beginning the day after 50th birthday

• Tests include– Digital rectal exam (DRE) G0102 w/V76.44

– PSA blood test G0103 w/V76.44


Smoking Cessation Services • Available to those with Medicare who use tobacco

(regardless of whether they have signs or symptoms of tobacco-related disease), competent and alert at time of counseling, whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner

• Cessation counseling– Up to 8 sessions per year

– Inpatient or outpatient

– Intermediate or intensive


• Part D can help pay for drug therapyPart D can help pay for drug therapy– Nicotine patches

– Other drugs

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Smoking & Tobacco-Use Cessation Counseling

• 99406 / G0436: Counseling visit; intermediate, greater than 3 minutes up to 1010 minutes

• 99407 /G0437: Counseling visit; intensive, greater than 10 minutes

• ICD-9 for individuals who do not have signs or symptoms of tobacco-related disease:– 305.1 (non-dependent tobacco use disorder)

– V15.82 (history of tobacco use)

G Codes vs 90000 Codes

• Medicare will waive the deductible and coinsurance / copayment for p ycounseling and billing with G codes on or after January 1, 2011

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Influenza (“Flu”) Vaccine

• Flu vaccine covered for all people with Medicare

• Once each flu season


HCPCS Codes for Influenza Virus Vaccine

Code Description

Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for IM use (Afluria)

Q2036 ---when administered to individuals 3 years of age and older, for IM use (Flulaval)

Q2037 ---when administered to individuals 3 years of age and older, for IM use (Fluvirun)

Q2038 ---when administered to individuals 3 years of age and older, for IM use (Fluzone)

Q2039 ---when administered to individuals 3 years of age and older, for IM use (Not Otherwise Specified)

G0008 Administration

V04.81 Need for prophylactic vaccination and inoculation against viral diseases; influenza

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CPT for Influenza Virus Vaccine

Code Description

90655 Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for IM use

90656 --- 3 years and older, IM use

90657 Influenza virus vaccine, split virus, when administered to children 6-35 months of age for IM use

90658 --- 3 years of age and older, for IM use

90660 Influenza virus vaccine, live, for intranasal use

90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen contentenhanced immunogenicity via increased antigen content, for IM use

Pneumococcal VaccineCode Description

90669 Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use

90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use

G0009 Administration of pneumococcal vaccine

V03.82 Need for prophylactic vaccination and inoculation against bacterial diseases; other specified vaccinations against single bacterial diseases; Streptococcus pneumoniae (pneumococcus)

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Pneumococcal Vaccine cont.

• Medicare may cover additional vaccinations based on risk

All people age 65 and older– All people age 65 and older

– Immunocompetent adults who are at increased risk of pneumococcal disease or it complications because of chronic illness

• e.g., cardiovascular disease, pulmonary disease, diabetes mellitus, alcoholism, cirrhosis, or cerebrospinal fluid leaks

– Individuals with compromised immune systems• e.g., splenic dysfunction or anatomic asplenia,

Hodgkin’s, lymphoma, multiple myeloma, chronic renal failure, HIV, nephrotic syndrome, sickle cell, or organ transplantation

Influenza and Pneumococcal Billed the Same Day

• Influenza CPT Code– Administration: G0008

• Pneumococcal CPT Code– Administration: G0009

• Diagnosis code when both are billed on the same day– V06.6

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Hepatitis B Vaccine

• Covered for high risk– End-stage renal disease

– Hemophilia who received Factor VIII or IX concentrates

– Clients of institutions for the mentally handicapped

– Persons who live in the same household as a Hepatitis B Virus (HBV) carrierp ( )

– Illicit injectable drug users

Hepatitis B Vaccine

• Intermediate Risk Groups– Staff in institutions for the mentally y

handicapped

– Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work


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Hepatitis B VaccineHCPCS

CodeDescription

90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule) for intramuscular use(3 dose schedule), for intramuscular use

90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use

90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule) for intramuscular use

90746 Hepatitis B vaccine, adult dosage, for intramuscular use

90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule) for intramuscular use(4 dose schedule), for intramuscular use

G0010 Administration of Hepatitis B vaccine

V05.3 Need for prophylactic vaccination and inoculation against single diseases; Viral hepatitis

Medical Nutrition Therapy (MNT)

• Coverage for diabetes or renal disease (not receiving dialysis)( g y )– Up to 3 hours in first year

– Up to 2 hours in subsequent years

• 97802, 97803, 97804 Initial Episode

• G0270, G0271 Second Referral within first year– Co-insurance, co-pay and/or deductible

waived

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Preventive Services Resource GuideMedicare.govmedicare.gov

1-800-MEDICARE(1-800-633-4227)(TTY 1-877-466-2048)

Medline Plusnlm.nih.gov/medlineplus

American Cancer Societycancer.org

1-800-ACS-2345(1-800-227-2345)

American Diabetes Associationdiabetes.org

Medicare & You HandbookCMS (Product No. 10050)

Medicare Coverage of Diabetes Supplies & Services (CMSMedicare Preventive Services To Help Keep You Healthynlm.nih.gov/medlineplus

Local State Health Insurance ProgramsSee the Medicare & You Handbook for a complete listing

Centers for Disease Controlcdc.gov

Flu Informationflu gov

1-800-DIABETES(1-800-342-2383)

Help Keep You Healthy(CMS Product No. 10110)

Your Medicare Benefits (CMS Product No. 10116)

flu.gov

HHS Tobacco Cessation Resourcessurgeongeneral.gov/tobacco

National Cancer Institutecancer.gov 1-800-4CANCER(TTY-1-800-332-8615)

Quick Reference to Medicare Services

• Advanced Beneficiary Notice Booklet

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Medicare Resources• Medicare Preventive Services

Manual

• Medicare Immunizations

• Medicare AWV

Medicare Resources

• Smoking Cessation

• Medicare IPPE Quick Reference

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Questions??

Thank You. Y’all Come [email protected]

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