Chapter 25
Preventive Services

25.1 Preventive Services

a. Hepatitis B Vaccination

Payment will be made at 80 percent of Medicare's allowed amount and is subject to regular Medicare Part B deductible and coinsurance provisions for the Hepatitis B vaccine and its administration. Payment for hepatitis B vaccine and its administration is only available to Medicare beneficiaries who are at high or immediate risk of contracting hepatitis B.

b. Influenza Virus Vaccination

Medicare does not require the vaccine be ordered by a doctor of medicine or osteopathy; therefore a beneficiary may receive the vaccine upon request without a physician's order and without physician supervision. However, the provider of flu shots must have a Medicare provider identification number in order to bill Medicare for payment. Medicare will generally pay for only one flu shot per beneficiary each flu season.

Medicare Part B reimburses for the influenza vaccine and its administration at 100 percent of the Medicare allowance. The Medicare Part B deductible and coinsurance do not apply for beneficiaries with standard fee-for-service Part B coverage.

c. Pneumococcal Pneumonia Vaccination

Payment for the vaccine and its administration will be made at 100 percent of Medicare's allowed amount. The Medicare Part B deductible and coinsurance do not apply for beneficiaries with standard fee-for-service Part B coverage.

Note: The August 1998, billing guide for flu and pneumonia services contains the most recent information. You may obtain this information on our website at www.hgsa.com/bugides.shtml. Additionally, you may order Medicare Medical Policy Bulletin (MMPB) I-8 (Immunization) through our faxback system at (717)763-5700 by requesting document number 5082.

d. Colorectal Cancer Screening

Section 4104 of the Balanced Budget Act of 1997 provides coverage of various colorectal screening examinations subject to certain coverage, frequency, and payment limitations. Effective for services furnished on or after January 1, 1998, Medicare will cover colorectal cancer screening test/procedures for the early detection of colorectal cancer. The Freedom of Information Medicare Medical Policy Bulletin G-36 (Colorectal Cancer Screening) identifying the coverage provided is available through our FaxBack system,
(717) 763-5700, document number 5516.

e. Prostate Cancer Screening

Section 4103 of the Balanced Budget Act of 1997 provides coverage of various prostate cancer screening examinations subject to certain coverage, frequency, and payment limitations. Effective for services furnished on or after January 1, 2000, Medicare will cover prostate cancer screening test(s)/procedure(s) for the early detection of prostate cancer.

G0102 Prostate Cancer Screening; Digital Rectal Examination

G0103 Prostate Cancer Screening; Prostate Specific Antigen Test (PSA)

Note: Please reference Medicare Medical Policy Bulletin L-52 (Medical Necessity Guidelines for Prostatic Specific Antigen (PSA)), which may be requested through our faxback system at (717) 763-5700, document number 5552.

f. Screening Pap Smear and Screening Pelvic Examination

f.1 Screening Pap Smear Coverage

Effective for dates of service on or after January 1, 1998, the coverage criteria for screening Pap smears has changed. Screening Pap smears are covered every 3 years, or more frequently for women at high risk for cervical or vaginal cancer, or of childbearing age who have had a Pap smear during any of the preceding 3 years indicating the presence of cervical or vaginal cancer or other abnormality. For women at high risk or for women who qualify for coverage under the childbearing provision, a screening Pap smear will be paid once per year. At least 11 months must have passed since the date of the last screening Pap smear covered by Medicare.

Screening Pap smears are covered when ordered and collected by a doctor of medicine or osteopathy or other authorized practitioner (e.g., a certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist, who is authorized under state law to perform the examination) under one of the following conditions:

1. The beneficiary has not had a screening Pap smear test during the preceding 3 years (use ICD-9-CM code V76.2, special screening for malignant neoplasm, cervix), or

2. There is evidence (on the basis of her medical history or other findings) that she is of childbearing age and has had an examination that indicated the presence of cervical or vaginal cancer or other abnormalities during any of the preceding 3 years, or that she is at high risk of developing cervical or vaginal cancer (use ICD-9-CM code V15.89, other specified personal history presenting hazards to health).

The term "woman of childbearing age" means a woman who is premenopausal, and has been determined by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or other findings.

f.2 Screening Pap Smear Coding Guidelines

Use these HCPCS codes to report screening Pap smear services.

G0123 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservation fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision (Effective for services on or after January 1, 1998)

G0124 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservation fluid, automated thin layer preparation, requiring interpretation by physician (Effective for services on or after January 1, 1998)

G0141 Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
(Effective for services on or after January 1, 1999)

G0143 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual evaluate and reevaluation by cytotechnologist under physician supervision
(Effective for services on or after January 1, 1999)

G0144 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual evaluation and computer-assisted reevaluation by cytotechnologist under physician supervision (Effective for services on or after January 1, 1999)

G0145 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual evaluation and computer-assisted reevaluation using cell selection and review under physician supervision (Effective for services on or after January 1, 1999)

G0147 Screening cytopathology smears, cervical or vaginal; performed by automated system under physician supervision (Effective for services on or after January 1, 1999)

G0148 Screening cytopathology smears, cervical or vaginal, performed by automated system with manual reevaluation (Effective for services on or after January 1, 1999)

P3000 Screening pap smear, cervical or vaginal, up to three smears, by technician under physician supervision

P3001 Screening pap smear, cervical or vaginal, up to three smears, requiring interpretation by physician

Q0091 Screening Papinolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory

The Part B deductible for screening Pap smear services paid under the physician fee schedule is being waived effective January 1, 1998. This waiver of deductible affects codes Q0091, P3001-26, and G0124-26. Codes P3000, P3001, G0123 and G0124 are paid under the clinical diagnostic laboratory fee schedule and as such the Part B deductible does not apply.

Report either ICD-9 code V76.2 for asymptomatic women or V15.89 for those women who meet the high risk criteria.

Effective January 1, 1999, Q0091 may be billed with an evaluation and management visit if the visit is a separately identifiable procedure. In this case, modifier 25 should be reported.

f.3 Screening Pelvic Examination Coverage

Effective for dates of service on or after January 1, 1998, a screening pelvic examination is covered for all female beneficiaries. A screening pelvic examination should include at least seven of the following eleven bulleted elements:

Inspection and palpation of breasts for masses or lumps, tenderness, symmetry , or nipple discharge;

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

Pelvic examination (with or without specimen collection for smears and cultures) including:

External genitalia (for example, general appearance, hair distribution, or lesions);

Urethral meatus (for example, size, location, lesions, or prolapse);

Urethra (for example, masses, tenderness, or scarring);

Bladder (for example, fullness, masses, or tenderness);

Vagina (for examples, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele);

Cervix (for example, general appearance, lesions or discharge);

Uterus, (for example, size, contour, position, mobility, tenderness, consistency, descent, or support);

Adnexa/parametria (for examples, masses, tenderness, organomegaly, or nodularity); and

Anus and perineum

Medicare Part B pays for a screening pelvic examination if it is performed by a doctor of medicine or osteopathy, or by a certified nurse midwife, a physician assistant, nurse practitioner, or clinical nurse specialist who is authorized under State law to perform the examination. This examination does not have to be ordered by a physician or other authorized practitioner.

Payment may be made for a screening pelvic examination performed on an asymptomatic woman (use ICD-9 code V76.2) only if the individual has not had a screening pelvic examination paid for by Medicare during the preceding 35 months following the month in which the last Medicare-covered screening pelvic examination was performed except as provided in the following situations:

1. Payment may be made for a screening pelvic examination performed more frequently than once every 36 months if the test is performed by a physician or other practitioner and there is evidence that the woman is at high risk (on the basis of her medical history or other findings) of developing cervical cancer or vaginal cancer (use ICD-9 code V15.89).

2. Payment may also be made for a screening pelvic examination performed more frequently than once every 36 months if the examination is performed by a physician or other practitioner, for a woman of childbearing age, who has had such an examination that indicated the presence of cervical or vaginal cancer or other abnormality during any of the preceding 3 years (use ICD-9 code V15.89). The term "woman of childbearing age" means a woman who is premenopausal, and has been determined by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or other findings.

3. Payment is not made for a screening pelvic examination for women at high risk or who qualify for coverage under the childbearing provision more frequently than once every 11 months after the month that the last screening pelvic examination covered by Medicare was performed.

f.4 Screening Pelvic Examination Coding Guidelines

Use the following HCPCS code to report screening pelvic examinations:

G0101 Cervical or vaginal cancer screening, pelvic and clinical breast examination

Report either ICD-9 code V76.2 for asymptomatic women or V15.89 for those women who meet the high risk criteria.

The Part B deductible for screening pelvic examinations is waived effective
January 1, 1998.

A screening Pap smear and a screening pelvic examination can be done during the same encounter. When this happens, both procedure codes should be reported (e.g., G0101 and Q0091). Effective April 1, 1999, procedure codes G0101 and Q0091 may be billed with an E& M visit, if the visit is a separately identifiable service. Modifier -25 should be reported in this situation.

f.5 High Risk Factors for Screening Pap Smears and Screening Pelvic Exams

Cervical High Risk Factors:

Early onset of sexual activity (under 16 years of age)

Multiple sexual partners (five or more in a lifetime)

History of a sexually transmitted disease (including HIV infection)

Fewer than three negative Pap smears within the previous 7 years

Vaginal Cancer High Risk Factors:

DES (diethylstilbestrol)-exposed daughters of women who took DES during pregnancy

25.2 Mammographies

a. Screening Mammographies

a.1 Mammography Certification

The Mammography Quality Standards Act (MQSA) of 1992 requires that all facilities providing mammography services (both diagnostic and screening) meet national quality standards. The Food and Drug Administration (FDA) is responsible for surveying mammography facilities and issuing certification number. If you have not received your six digit certification number or would like to become certified, please contact the FDA Hotline at 1-800-838-7715.

Mammography facilities that perform mammographies should not release x-rays for interpretation to physicians who are not approved under the facility's certification number, except:

when the patient has requested transfer of the films from one facility to another for a second opinion, or

when the patient has moved to another part of the country where the next screening mammography will be performed.

Interpretations should only be performed by physicians who are associated with the certified mammography facility.

Note: Providers are encouraged to inform their patients about centers that they know have been certified by the FDA.

a.2 Screening Mammographies Covered When Performed by Certified Provider

Medicare Part B provides coverage for a screening mammography when performed by a certified provider. A screening mammography is a routine radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician's interpretation of the results of the procedure.

Use procedure code 76092, screening mammography, bilateral (two view study of each breast) to report this service. Do not report this procedure code twice, or report the 50 modifier, to indicate that the service was performed bilaterally. Do not report the 52 modifier to indicate that the service was reduced to a unilateral view. Reimbursement is made based upon the procedure being performed bilaterally.

All claims for mammography services (both technical and global components) must be reported with the FDA six digit certification umber. Claims submitted without the certification number will be denied.

This certification number should be reported in the appropriate record/block as follows:

Electronic Claims Paper


Item ANSI ASC X12 National PCE HCFA-1500
Standard
Format

6-digit Prior Prior Mammo Name and
Certification Authorization Authorization Cert # Address of
Number Number Number Field Facility Where Services Were
Rendered

2-470.B Record FA0 Mammo Block 23
Ref Segment Postions Cert #
02 Data 142-151 Field
Element

a.3 ICD-9 CM Diagnosis Codes and Frequency Limitations

Effective for dates of service on or after January 1, 1998, Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening mammographies for women ages 40 and over and waives the Part B deductible.

Payment of a screening mammography is made based on the beneficiary's age, and statutory frequency parameters as follows:

Age Eligibility Screening Period

35-39 (all) Baseline (only one screening
allowed for women in this age group)

40 and Over Annual (11 full months must have
elapsed following the month of the last screening)

Note: Count months between mammographies beginning the month after the date of the examination. For example, if Mrs. Smith received a screening mammography examination in January 1999, begin counting the next month (February 1999) until 11 months have elapsed. Payment can be made for another screening mammography in January 2000.

A beneficiary who was in the age category for a yearly screening mammography, but has a birthday which puts her in the biennial screening category before her next annual screening, must wait for the biennial period to pass. For example, the beneficiary received a screening mammography in April 1998 at age 64. She turned 65 in June of 1998. She must wait until 11 months have elapsed following the month of the last screening (April 1998) before payment can be made for another screening mammography. In this case, payment could be made in April of 1999) for her next screening mammography.

a.3.1 Use Appropriate Diagnosis Code

Report the following ICD-9 code on all claim submissions for screening mammogram performed on or after January 1, 1998:

V76.12 Special screening for malignant neoplasm, breast, other screening mammogram

Note: Mammography services performed prior to January 1, 1998 should be reported using the previous guidelines (e.g., diagnosis codes reflective of lo or high risk status).

b. Diagnostic Mammographies

A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs or symptoms of breast disease, a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician's interpretation of the results of the procedure.

A mammogram is medically necessary and is a covered diagnostic radiological study under any of the following conditions:

1. The patient has a personal history of breast cancer (V10.3).

2. The patient has distinct signs and symptoms for which a mammogram is indicated, such as but not limited to:

breast mass or nodes- 611.72

painful (611.71) or tender breasts

change in color, surface, size and/or shape of breast, nipple or skin

nipple discharge - 611.79

3. Based on the patient's history and other significant factors, a mammogram is appropriate. Conditions such as, but not limited to those listed below, indicate the medical necessity for mammograms:

metastases or nodes in areas of the body other than the breast but the primary site is unknown

history or presence of endometrial cancer

previous suspicious lesions or masses of the breast

where evaluation by palpation is difficult because of large fatty breasts, augmented breasts, or implanted breasts

Report the ICD-9-CM diagnosis code(s) which reflects the patient's signs, symptoms, conditions, or complaints.

Use the following procedure codes to report diagnostic mammographies:

Code Description

76090 Mammography, unilateral

76091 Mammography; bilateral


When both a screening mammography (76092) and a diagnostic mammography (76090, 76091) are reported for the same date of service, the National Correct Coding Combinations will be applied.

b.1 Billing for Screening Mammogram Elevated to a Diagnostic Mammogram

Medicare allows a radiologist to order additional mammography views when a screening mammography shows a potential problem. If the interpretation results in additional films, the mammography is no longer considered a screening exam and only the diagnostic x-ray(s) should be billed. The original screening test should not be billed as it does not meet the requirements for age, frequency or payment purposes.

To bill a diagnostic mammogram converted from a screening mammogram, use CPT code 76090 (unilateral) or 76091 (bilateral) and GH modifier: "Diagnostic mammogram converted from screening mammogram on the same day." Payment is based on the fees for diagnostic mammographies.

b.2 Mammography for Fibrocystic Disease

Fibrocystic disease (610.1) in and of itself does not indicate medical necessity for a diagnostic mammogram. However, a patient diagnosed with fibrocystic disease and experiencing suspicious changes, signs, or symptoms as specified in items #1 and #3 above would be eligible for a diagnostic mammogram.

A patient who does not have signs or symptoms of breast disease but who has a personal history of biopsy-proven breast disease would be considered eligible for a diagnostic mammogram.

25.3 Routine Physical Exam

When a doctor sees an asymptomatic patient for a head-to-toe routine physical, the correct procedure code to report is 99397 (periodic preventive medicine evaluation and management for those 65 years and over). This preventive service is considered a program exclusion by Medicare, and therefore, having an advance beneficiary notification (ABN) signed by the patient prior to the service being rendered, is not required. Of course, in the interest of good patient relations, it is advisable to have the waiver signed in order that your patient is well informed. Nevertheless, since preventive evaluation and management (E/M) services are a program exclusion, you may bill your patient even if an ABN was not obtained.

When a physician furnishes a routine physical exam (99397), as well as a medically indicated or covered visit during the same encounter, the covered visit is viewed as being provided in lieu of a part of the routine physical.

Example: A patient comes to the office for a routine physical exam, and while there, asks the doctor to treat her for a case of poison ivy. She contacted it three days ago and it is getting worse. The doctor’s charge for a physical exam is $60. The doctor tends to the poison ivy, and the clinical circumstances of the case meet the criteria for a covered visit (99212). The Medicare allowance for the covered procedure (99212) is $35.

The physician may charge the beneficiary (as a charge for the non-covered portion of the routine physical) the difference between the physician’s current established charge for the routine physical and the established charge for the covered visit, or $25 ($60 - $35). In this case, the physician should modify 99397 with the 52 modifier to indicate that it is a reduced service; it is being reduced by the covered portion. Reporting the 52 modifier with a non-covered code is the only instance in which additional documentation does not need to be attached to explain why the service is being reduced.

Similar logic is applied when 99397 is being rendered in conjunction with covered codes such as a pelvic and breast exam (G0101) and collection for the Pap smear (Q0091). The covered services should be carved out from the preventive E/M.

Example: A physician’s normal charge for 99397 is $60; the allowance for G0101 is $27; and the allowance for Q0091 is $25. The physician is still able to collect a total of $60, but Medicare will help pay for the G0101 and the Q0091 when coverage requirements are met. The physician should not expect to collect $112 ($60 + $25 + $27).

Effective for services rendered on and after January 1, 1999, a pelvic and breast exam (G0101) is separately reimbursable when it is rendered with a covered E/M that is a significant and separately identifiable service. In this circumstance, the 25 modifier should be attached to the E/M.

Effective for services rendered on and after April 1, 1999, collection for the Pap smear (Q0091) is separately reimbursable when it is rendered with a covered E/M that is a significant and separately identifiable service. Again, the 25 modifier is reported with the E/M to indicate this clinical circumstance.

It should be noted that since G0101 and Q0091 are covered services, if the Medicare program denies the services because they were rendered more frequently than what Medicare considers reasonable and necessary, an Advance Beneficiary Notice must be obtained from the patient prior to the service being rendered, or the beneficiary cannot be held financially responsible.