new added ankle foot cpt code L4631,B4034, B4035

HCPCS Code Update - 2011

The following list identifies changes to level II Healthcare Common Procedure Coding System (HCPCS) codes for 2011. Please refer to Change Requests 7064 and 7121 published on the Centers for Medicare and Medicaid (CMS) web site.

Added Codes/Added Modifiers: New codes and modifiers are effective for dates of service on or after January 1, 2011.
Discontinued Codes/Deleted Modifiers: Codes or modifiers that are discontinued / deleted will continue to be valid for claims with dates of service on or before December 31, 2010, regardless of the date of claim submission. If there is a direct crosswalk for a discontinued/deleted code or modifier, it is listed in the table. The crosswalked codes are also “added” codes effective for dates of service on or after January 1, 2011.
Narrative Changes/Revised Modifiers: A description change for an existing code or modifier is effective for dates of service on or after January 1, 2011.
The appearance of a code in this list does not necessarily indicate coverage.

Ankle-Foot/Knee-Ankle-Foot Orthoses
Added Code
Code	Narrative
L4631	ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM, ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHER MATERIAL, INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATED
Enteral Nutrition
	Narrative Changes
Code	Old Narrative	New Narrative
B4034	ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY	ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE
B4035	ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY	ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

Medicare payment for bilateral surgery procedure performed

Bilateral Surgery

50 Modifier Bilateral Procedure. Modifier 50 represents that the procedure was performed bilaterally. To report bilateral services, bill the procedure with the 50 modifier and a unit of one in the days/units field or electronic equivalent.

Example: 29870-50 $1,000 Units = 1

The billed charge should reflect a bilateral procedure amount if the procedure was performed bilaterally.
Note: Please refer to your current MPFSDB to determine whether a 50 modifier may be added on the procedure code being used.

Example: The following example demonstrates pricing of bilateral services billed.

Code Allowed Bilaterally on MPFSDB (50 Modifier)Unilateral Allowed Amount $ Final Allowance$
29870-50                             Yes                     365.31 x 150% = 547.96 (bilateral)       547.96 x 80%


Example: The following example demonstrates multiple surgery pricing logic as it is applies to bilateral surgeries.

Code            Indicator 50 Modifier Unilateral Allowed Amount $  Ranking   Final Allowance $

29870-50    2           Yes   365.31 x 150% = 547.96 (bilateral) 100%             547.96 x 80%
29345-50    2           Yes    115.04 x 150% = 172.56 (bilateral) 50%             86.28 x 80%

CPT code A4353 - coding guideline

Urological Supplies - A4353 Correct Coding Clarification Policy

The Coding Guidelines section of the Urological Supplies Policy Article has been revised to clarify the correct coding for use of HCPCS code A4353 (Urinary intermittent catheter with insertion supplies). The revised passage states:

A urinary intermittent catheter with insertion supplies (A4353) is a kit which includes a catheter and all supplies necessary for sterile insertion (see below). Code A4353 may be used if either 1 or 2 is supplied:

1. A sterile intermittent urinary catheter plus a separately packaged sterile kit of insertion/collection supplies; or,

2. A single sterile package containing both a catheter and all insertion/collection supplies.

The insertion kit (A4353) contains a catheter (may be packaged separately from the other components), lubricant, gloves, antiseptic solution, applicators, a drape, and a collection tray/bag in a sterile package intended for single use. The collection tray/bag is a separate item included as part of the kit; therefore, materials that serve as non-sterile packaging to contain all of the items in the kit do not meet this requirement. Except as noted in 1 above, code A4353 must not be billed if individual insertion kit components are provided as separate items. When providing a sterile kit, the individual components must not be separately billed.


Suppliers are reminded that payment for code A4353 includes both the catheter and all insertion supplies. Separate billing for the catheter and/or any insertion supplies is incorrect.

The Local Coverage Determination (LCD) section on Intermittent Catheterization also has been revised to be consistent with the Coding Guideline above. The revised material in the LCD states:

Refer to Coding Guidelines section of the related Policy Article for contents of the kit (A4353). A4353 should not be used for billing if the components are packaged separately rather than together as a kit. Separately provided components do not provide the equivalent degree of sterility achieved with an A4353. If separate components are provided instead of a kit (A4353) they will be denied as not reasonable and necessary.

Medicare endoscopic payment pricing method - Multiple procedure

Endoscopic Pricing Method

The endoscopic pricing method is denoted by an indicator of (3) under the “Mult Proc” column on the MPFSDB.

Calculate the allowance and limiting charge (non-assigned claims only) at:

One hundred percent for the procedure with the highest fee schedule amount.

Subsequent procedures equal subsequent procedure allowance minus basic endoscopic allowance.
The pricing formula for multiple endoscopic procedures varies depending on which procedures are billed.

Same Endoscopic Family

When two or more endoscopies are billed that are both in the same endoscopic family, Medicare prices the highest allowed procedure at 100 percent of the fee amount. The other procedures are priced by subtracting the fee amount of the basic endoscopy from their fee amounts.

Example: The following example demonstrates endoscopic pricing in the same endoscopic family.


Codes                Definition           Indicator Fee Amount $      Allowance $ 
45305©  Proctosigmoidoscopy w/bx 3 130.39 – 68.08 =       62.31 x 80%
45307© Proctosigmoidoscopy fb      3  138.62                      138.62 x 80%

Base Endoscopy

45300© Proctosigmoidoscopy dx 2   68.08

Different Endoscopic Family
When two or more endoscopies that are both in the same endoscopic family are billed along with another procedure that is either non-endoscopic or endoscopic from a different family, price the two endoscopies that are in the same family as indicated in Example 1. The allowance of the two procedures should be added together and then compared to the third procedure.

Example: The following example demonstrates endoscopic pricing from different endoscopic families.

Codes     Definition                     Indicator             Fee Amount $                        Allowance $
*45305© Proctosigmoidoscopy w/bx 3                 130.39 – 68.08 =  62.31        31.16  x 80%
                                                                            62.31 x 50% = 31.16
*45307© Proctosigmoidoscopy fb   3                138.62   138.62 x 50% = 69.31   69.31  x 80%

52325© Cystoscopy, stone removal 3        304.06 @ full physician allowance     304.06 x 80%

Can we bill Medicare patients when service get denied?

Billing Medicare Patients for Services Which May Be Denied



Medicare patients may be billed for services that are clearly not covered. For example,
routine physicals or screening tests such as total cholesterol are not covered when there is
no indication that the test is medically necessary. However, when a Medicare carrier is
likely to deny payment because of medical necessity policy (either as stated in their written
Medical Review Policy or upon examination of individual claims) the patient must be
informed and consent to pay for the service before it is performed. Otherwise, the patient
has no obligation to pay for the test.

An Advance Beneficiary Notice (ABN), sometimes called a patient waiver form, is used to
document that the patient is aware that Medicare may not pay for a test or procedure and
has agreed to pay the provider in the event payment is denied. Each ABN must be specific
to the service provided and the reason that Medicare may not pay for the service. Blanket
waivers for all Medicare patients are not allowed.

Since both LMRPs as well as the new NCD for A1c include frequency limits, an ABN is
appropriate any time the possibility exists that the frequency of testing may be in excess of
stated policy. For example, if an A1c test may have been performed by another provider
less than three months ago for a patient with uncomplicated diabetes, it would be prudent
to obtain a signed ABN.

The CPT code modifier, -GA (Waiver of Liability Statement on File), is used to indicate that
the provider has notified the Medicare patient that the test performed may not be
reimbursed by Medicare and may be billed to the patient.

An ABN must: (1) be in writing; (2) be obtained prior to the beneficiary receiving the
service; (3) clearly identify the particular service; (4) state that the provider believes
Medicare is likely to deny payment for the service; (5) give the reason(s) that the provider
believes that Medicare is likely to deny payment for the specific service, and (6) include
the beneficiary’s signature and date. Routine notices to beneficiaries which do nothing
more than state that Medicare denial of payment is possible, or that the provider never
knows whether Medicare will pay for a service, are not considered acceptable evidence of
advance notice.

Can we bill office visit when we done Lab cpt code?

Office Visits Primarily for the Purpose of HbA1c Testing

The following evaluation and management code may be billed in addition to 83036 or
83036QW for A1c testing under certain circumstances.

99211 Office or outpatient visit for the evaluation and management of an
established patient that may not require the presence of a physician.

Physician interpretation of test results is considered to be part of the evaluation and
management services provided to a patient during an office visit and is not separately
billable. However, if a patient sees a nurse or other non-physician health care professional
for the purpose of A1c testing (for example, to monitor insulin therapy) and the nurse takes
vital signs, compares the results of the A1c test to predetermined guidelines, and advises
the patient accordingly, 99211 may be billed.

Patients with abnormal results or other indications not covered by established guidelines
should always be referred to a physician. The level of office visit then reported would
depend on the evaluation and management services provided by the physician.

When a Metrika A1cNow test is provided to a patient by a physician for home testing at a
later date, the test may be submitted for payment when the patient notifies the physician of
the result and it is entered in the medical record. The date of service would be the date the
test is performed, not the date the test materials are provided to the patient. If the patient
fails to perform the test, the physician may bill the patient for the cost of the test materials;

however, the test itself can not be billed to Medicare or the patient since it was not
performed.

Medicare payment for multiple surgical procedure - standard pricing method

MULTIPLE SURGERY PRICING

Pricing Methods

According to Medicare guidelines, surgical procedures may be priced by two different pricing methods:

* Standard.
* Endoscopic.

Standard Pricing Method
The standard pricing method is denoted by an indicator of (2) under the “Mult Proc” column on the Medicare Physician Fee Schedule Database (MPFSDB). The allowance is calculated at:

* One hundred percent for the procedure with the highest fee schedule amount.
* Fifty percent for the second through fifth highest fee schedule amounts.

Each standard priced procedure after the fifth procedure requires submission of an operative report.
Standard Pricing Example

The following example demonstrates the standard pricing method:

Code Database Indicator Billed Amount $ Medicare Allowed Amount $ Ranking Allowance $
35301    2                             2,000             1,043.48                                   100%          1,043.48 x 80%
35201    2                           1,000                 922.90                                    50%            461.45 x 80%
35261    2                            1,050             1,010.60                                    50%           505.30 x 80%

covered DX for CPT 83036 - 211.7,250.00 V58.69

Diagnosis (ICD-9) Codes

An appropriate diagnosis (ICD-9) code (or narrative description) must be indicated for each
service or supply billed under Medicare Part B. ICD-9-CM is an acronym for International
Classification of Diseases, 9th Revision, Clinical Modification.

When a patient presents with an undiagnosed illness, the ICD-9 code is determined by the
"signs and symptoms" present. Symptoms are defined as what the patient tells the
physician. Signs are what the physician observes as part of his examination of the patient.

Definitive ICD-9 codes should only be assigned and recorded in the medical record after a
diagnosis is clearly determined. Terms such as "rule out", "probable", and "suspected"
should NOT be used since they can not be coded as such and may be interpreted as a firm
diagnosis by a third party payer.

ICD-9 Codes Covered by Medicare
211.7 Benign neoplasm of islets of Langerhans
250.00-250.93 Diabetes mellitus and related codes
251.0 Hypoglycemic coma
251.1 Other specified hypoglycemia
251.2 Hypoglycemia, unspecified
251.3 Post-surgical hypoinsulinemia
251.4 Abnormal secretion of glucagon
251.8 Other specified disorders of pancreatic internal secretion
251.9 Unspecified disorder of pancreatic internal secretion
258.0-258.9 Polyglandular dysfunction and related disorders
271.4 Renal glycosuria
275.0 Disorders of iron metabolism (hemachromatosis)
577.1 Chronic pancreatitis
579.3 Other and unspecified post-surgical nonabsorption
648.00 Diabetes mellitus complicating pregnancy, unspecified episode
648.03 Diabetes mellitus complicating pregnancy, antipartum complication
648.04 Diabetes mellitus complicating pregnancy, postpartum complication
648.80 Abnormal glucose tolerance complicating pregnancy, unspecified episode
648.83 Abnormal glucose tolerance complicating pregnancy, antipartum complication
648.84 Abnormal glucose tolerance complicating pregnancy, postpartum complication
790.2 Abnormal glucose tolerance test
790.6 Other abnormal blood chemistry (hyperglycemia)
962.3 Poisoning by insulin and antidiabetic agents
V12.2 Personal history of endocrine, metabolic, and immunity disorders
V58.69 Long term current use of other medication

CPT code 99406 - Tobacco Use Cessation Counseling

Tobacco Use Cessation Counseling

Medicare covers counseling for tobacco cessation for outpatients and for inpatients. Inpatients are covered only if counseling for tobacco use is not the primary reason for the patient’s hospital stay. Medicare covers 2 cessation attempts per year.

The counseling during an E/M service must be either intermediate or intensive. Intermediate counseling is 2 to 3 sessions of 3 to 10 minutes each. Intensive counseling is 4 sessions of more than 10 minutes each. Counseling involving only 1 session lasting less than 3 minutes is considered part of an E/M service and is not reimbursed separately. Each attempt may include a maximum of four intermediate or intensive counseling sessions. The total annual benefit is for 8 sessions in a 12 month period.

Services may be provided by a physician, physician assistant, nurse practitioner, clinical nurse specialist, qualified psychologist or clinical social worker. CMS does not currently have specific training requirements, but may in the future. The counseling must be provided face-to-face with the patient.

These services are reported using CPT-4 code 99406 (intermediate, E/M counseling service) or code 99407 (intensive, E/M counseling service). The diagnosis code should reflect the condition the patient has that is adversely affected by tobacco use or the condition the patient is being treated for with a therapeutic agent whose metabolism or dosing is affected by tobacco use.

Medicare Payment for Clinical Laboratory Services - 83036

Before Medicare pays for any test or diagnostic service, two basic criteria must be met:
(1) the service must be covered by Medicare (e.g., certain procedures such as
routine screening tests are not covered) and

(2) the service must be medically necessary or indicated.

Once these two criteria are met, Medicare pays for most clinical laboratory tests based on
the Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and
adjusts payment levels annually on January 1st based on Congressional budget
recommendation.

Medicare payment for clinical laboratory tests is always the lesser of the fee schedule
amount or the actual amount billed. The provider must accept the Medicare reimbursement
as payment in full for a laboratory test. Medicare patients may NOT be billed for any
additional amounts. Tests must be billed directly to Medicare by the laboratory or physician
performing the test. If an outside laboratory performs a test on a referral from a physician,
only the reference laboratory may legally bill Medicare for the procedure.


Procedure (CPT) Codes and Modifiers

The CPT codes for Glycated Hemogobin (A1c) determinations are:
83036 Hemoglobin; glycated (A1c)
83036QW Hemoglobin; glycated (A1c) using CLIA waived method

Medicare reimbursement for CPT codes 83036 and 83036QW is $13.42 in all states
except:
Idaho: $9.66 Maryland: $12.66 Oklahoma: $11.95
Rhode Island: $12.09 South Dakota: $12.86 Wyoming: $10.49

cpt code 80061, 82465,84478 - Cardiovascular Screening Blood Tests

Cardiovascular Screening Blood Tests

This benefit provides a blood test for the early detection of cardiovascular disease or abnormalities associated with an elevated risk of this disease. Three clinical laboratory tests are covered—total cholesterol, high density lipoprotein (HDL), and triglycerides. These tests are covered once every five years and can be ordered as one of each individual test or combination as a panel.

The tests must be ordered by a treating physician and used in the management of the patient. Laboratories must offer physicians the ability to order a lipid panel without the direct low density lipoprotein (LDL) measurement. However, if the screening lipid panel results illustrate a triglycerides level that indicates the need for a direct LDL measurement, the physician may order this test.

Report procedure codes for lipid panel (80061) or the individual codes for the tests included in the panel (82465, 84478, or 83718). Report a diagnosis code from the series V81.0-V81.2 (special screening for cardiovascular diseases).

Does Medicare cover reventive Physical Examination - V70.0

Initial Preventive Physical Examination

This examination (referred to as the IPPE or “Welcome to Medicare Exam”) covers specific services for new Medicare beneficiaries. The exam is payable once and only if provided within the first twelve months of the beneficiary’s first Part B coverage period. The usual deductible is waived, but co-insurance provisions apply.

The service may be provided by a physician or qualified non-physician provider (e.g., physician assistants (PA), nurse practitioners (NP), and clinical nurse specialists (CNS).

The IPPE includes the following:

• Medical and social history: Review of patient’s history with particular attention to modifiable risk factors for disease.

• Depression Risk Assessment: Review of the patient’s risk factors for depression, including current or past experience with depression or other mood disorders. She cannot have a current diagnosis of depression. The provider may use one of the standardized screening tests designed for this purpose and recognized by national medical professional organizations.

• Functional ability and level of safety: Review based on the use of appropriate screening questions or a screening questionnaire. The provider may select from screening questions or standardized questionnaires designed for this purpose and recognized by national medical professional organizations.

• Examination: Measurements and tests including measurement of the patient’s height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate, based on her medical and social history and current clinical standards.

• Effective January 1, 2009, the examination element of the IPPE now requires measurement of body mass index to identify those at risk for weight-related health problems.

• Optional Electrocardiogram: Performance and interpretation by provider or by referral provider.

• Education, counseling, and referral: Provided as appropriate, based on the results of the first five elements of the IPPE.

• End of Life Planning (Upon an individual’s consent): End-of-life planning is defined as verbal or written information regarding: (1) an individual’s ability to prepare an advance directive (AD) in the case that an injury or illness causes the individual to be unable to make health care decisions, and (2) whether or not the physician is willing to follow the individual’s wishes as expressed in the AD.

• Brief written plan such as a checklist: Provided to the patient for obtaining appropriate screening and other preventive services which are separately covered under Medicare Part B benefits (e.g., screening services described above, vaccinations, diabetes self-management, glaucoma screening, medical nutrition therapy)

For the purposes of the IPPE benefit, medical history is defined as:

• Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatment.
• Current medications and supplements, including calcium and vitamins.
• Family history, including a review of medical events in the patient’s family, including diseases that may be hereditary or place the individual at risk.

For the purposes of this benefit, social history is defined as:
• History of alcohol, tobacco, and illicit drug use.
• Diet.
• Physical activities.

If the physician or NPP cannot perform the EKG in the office suite, then alternative arrangements may be made with an outside entity. The primary care provider must incorporate the results of the EKG into the beneficiary’s medical record.

The following HCPCPS codes are used to report these services:

• G0402 - Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during first six months of Medicare enrollment

• G0403 - Electrocardiogram, routine ECG with at least 12 leads: with interpretation and report, performed as a component of the initial preventive physical examination

• G0404 - Tracing only, without interpretation and report, performed as a component of the initial preventive physical examination

• G0405 - Interpretation and report only, performed as a component of the initial preventive physical examination

The diagnosis code reported is V70.0 (routine general medical examination at a health care facility).
Other covered preventive, screening or problem-oriented services may be performed at the same encounter as the IPPE. These are reported using the appropriate codes. If reporting an E/M service, add a modifier 25. The documentation for the problem-oriented portion of the encounter must support the level of service reported.

CPT 82270, g0107 - Colorectal Cancer Screening - DX V76.41, V76.51

Colorectal Cancer Screening

Medicare covers one screening fecal-occult blood test for women 50 years and older once every 12 months. The attending physician must submit a written order for the test.

Beginning January 1, 2007, the guaiac based screening should be reported to Medicare using CPT code 82270 rather than HCPCS code G0107. The descriptor for CPT code 82270 reads “Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection).” Therefore the patient must complete the test by taking samples from consecutive stools.

As an alternative to the guaiac-based fecal occult blood test, (FOBT), reported with CPT-4 code 82270, Medicare also covers screening performed by immunoassay. It is reported to Medicare using HCPCS code G0328 (colorectal cancer screening; fecal occult blood test immunoassay, 1-3 simultaneous). The number of specimens required depends on the individual manufacturer’s instructions. However, Medicare will pay for only one covered FOBT per year, either 82270 or G0328, but not both.

The diagnosis code reported is either V76.41 (special screening for malignant neoplasms, rectum) or V76.51 (special screening for malignant neoplasms, colon). The patient is not responsible for any copay or deductible.

Screening Mammography CPT code 77057, 77052 - DX v76.12

 
Screening Mammography

Medicare covers one screening mammogram for women aged 40 years or older once every 12 months. CPT code 77057 (screening mammography, bilateral [two view film study of each breast]) is reported if a standard screening mammogram is performed. Medicare also covers computer aided detection (CAD) technology when performed in addition to the standard mammography. This service is reported using CPT add-on code +77052 (computer-aided detection (computer algorithm analysis of digital image data for lesion detection); screening mammography) in addition to code 77057. The Medicare deductible is waived for this service but the patient is responsible for 20% of the Medicare approved amount.


In April 2001, Medicare began to cover and provide additional payment for the use of digital technology for screening and diagnostic mammography studies. HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views) was developed to be reported for a screening full-field digital (FFDM) mammogram. Diagnosis code(s) V76.11 (screening mammogram for high-risk patient) or V76.12 (other screening mammogram) should be linked to the appropriate CPT-4 mammography code reported. The Medicare deductible is waived for this service but the patient is responsible for 20% of the Medicare approved amount.


A diagnostic mammogram (when the patient has an illness, disease or symptoms indicating the need for a mammogram) is covered whenever it is medically necessary.

MEDICARE PREVENTIVE SERVICES CPT 77078,77079, 77081

OTHER MEDICARE PREVENTIVE SERVICES

Following are brief descriptions of other preventive services covered by Medicare and sometimes provided by obstetrician/gynecologists.

Bone Mass Measurements

Medicare covers bone mass measurements every two years for qualified individuals. The patient is responsible for meeting her Medicare Part B deductible and for her 20% co-payment.
A “qualified individual” meets at least one of these medical indications:
• Estrogen-deficient and at clinical risk for osteoporosis
• Vertebral abnormalities as demonstrated by an x-ray
• Receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5.0 mg of prednisone or greater, per day, for more than 3 months
• Has a diagnosis of primary hyperparathyroidism
• Being monitored to assess the response to or efficacy of an FDA – approved osteoporosis drug therapy

Medicare may pay for more frequent screenings when medically necessary. Examples include, but are not limited to, the following medical circumstances:

• Monitoring beneficiaries on long-term (more than 3 months) glucocorticoid (steroid) therapy
• Confirming baseline BMMs to permit monitoring of beneficiaries in the future


Procedure Codes
Medicare allows the physician to choose the screening test. As of January 1, 2007, the CPT/HCPCS coding options are:

77078 Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
77079 appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77080 Dual energy x-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77083 Radiographic absorptiometry (photodensitometry, radiogrammetry), one or more sites
76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method
G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites, appendicular skeleton (peripheral; e.g., radius, wrist, heel)

Diagnosis Codes

Local carriers determine the ICD-9-CM diagnostic codes that they will accept as supporting these indications. The test must be ordered by a physician or a qualified nonphysician practitioner who is treating the patient. Qualified nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and nurse-midwives. The test results must be required as part of the patient’s evaluation and/or formulation of a treatment plan.

billing Medicare screening CPT with E & M code

MEDICARE SCREENING SERVICE AT THE TIME OF COVERED E/M SERVICES

Medicare will reimburse separately for covered screening services (e.g., G0101, Q0091) when performed at the same encounter as a covered E/M service, such as a problem-oriented visit (codes 99201-99215). The level of E/M service reported is based solely on the evaluation of the problem.

Example : Covered problem-oriented visit reported with a screening pelvic examination (G0101) and collection of a screening Pap smear specimen (Q0091).

Bill to :	CPT/HCPCS Code(s)	ICD-9 Code(s)	Charge
Medicare	99213-25	Problem diagnosis	$61.20
	G0101-GA	V76.2, V76.47, V76.49, or V15.89	$34.60
	Q0091-GA	V76.2, V76.47, V76.49, or V15.89	$40.00
Patient	N/A	N/A	$135.80

The GA modifier indicates that an ABN has been signed. Modifier 25 indicates that the E/M service was significant and separately identifiable and not part of the pelvic examination or collection of the Pap smear.

The patient is not billed for her portion until Medicare has processed the claim. The diagnosis code for the patient’s problem, signs or symptoms should be linked to the E/M service (99213). The level of service for the E/M visit will depend on what was performed and documented.

CPT code q0091 - Pap smear specimen

COLLECTION OF SCREENING PAP SMEAR SPECIMEN

Medicare reimburses for collection of a screening Pap smear every two years in most cases. This service is reported using HCPCS code Q0091 (Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). The patient does not have to meet her Part B deductible, but is responsible for 20% of the Medicare approved amount for the service. For the laboratory’s interpretation of the test, the patient does not need to pay a copay nor meet her deductible.

The collection is reimbursed every year if the patient meets Medicare’s criteria for high risk. Following are the only criteria that are accepted by Medicare to indicate a high risk patient:

• Woman is of childbearing age AND
       o cervical or vaginal cancer is present (or was present) OR
       o abnormalities were found within last 3 years OR
       o is considered high risk (as described below) for developing cervical or vaginal cancer.
• Woman is not of childbearing age AND she has at least one of the following:
       o High risk factors for cervical cancer:
�� Onset of sexual activity under 16 years of age
�� Five or more sexual partners in a lifetime
�� History of sexually transmitted disease (including the human papillomavirus and/or HIV infection);
�� Fewer than 3 negative Pap smears within previous 7 years
�� No Pap smears at all within the previous 7 years
        o High risk factor for vaginal cancer:
�� She had been exposed to DES in utero