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Here’s a checklist of items added to Medicare’s list of covered services during 2001 that you can use to ensure your practice is getting properly paid:
• Preventive services. During 2001, Medicare expanded coverage for screening tests for breast, cervical, and colorectal cancers. Starting on Jan. 1, 2002, Medicare will also cover an annual glaucoma screening test and medical nutrition therapy by registered dietitians for people with diabetes and a renal disease.
The extended coverage comes from the Beneficiary Improvements and Protections Act (BIPA) enacted by Congress in December 2000. The legislation directs the Centers for Medicare and Medicaid Services (CMS) to phase in specific coverage for certain tests and therapies that can detect diseases early, when they are most easily treated or cured.
The newly covered services include a Pap test and a pelvic exam every two years (instead of every three years) for women not at high risk for uterine or vaginal cancers, effective July 1, 2001. Medicare will pay for screening Pap smears and pelvic exams, which include clinical breast exams, every two years for women who are post-menopausal and/or not at high risk for cervical or vaginal cancer.
Medicare still covers an annual screening Pap smear and pelvic exam for women of childbearing age who have had an abnormal Pap smear within three years or are considered at high risk for cervical or vaginal cancer. "Medicare considers a woman at high risk if she has a prior history of cancer or sexually transmitted disease; began having sexual intercourse before age 16; has had more than five sexual partners; has not had a Pap smear within seven years; or has a mother who used diethylstilbestrol during pregnancy," notes Brett Baker, a reimbursement specialist with the American College of Physicians - American Society of Internal Medicine (ACP-ASIM).
Coding tip: Use HCPCS G0101 to report a pelvic exam. Medicare will pay separately for a screening pelvic and clinical breast exam, G0101, and for obtaining a specimen for a Pap smear, Q0091, when the two services are billed together for the same patient on the same date when billed with an evaluation and management service, as long as it is appended with modifier -25.
Also, Medicare will still pay separately for a pelvic and clinical breast exam performed during a medically necessary office visit, even if you do not obtain a specimen for a screening Pap smear. But make sure you append the evaluation and management service with modifier -25 and bill G0101 for the pelvic and clinical breast exam.
Medicare will pay for screening colonoscopy every 10 years for people not at high risk for colorectal cancer effective, last July 1. Medicare defines high risk as individuals who have a family history of colorectal cancer; prior experience with cancer or precursor neoplastic polyps; a history of chronic digestive disease conditions (including inflammatory bowel disease, Crohn’s disease, or ulcerative colitis); the presence of any appropriate recognized gene markers for colorectal cancer; or other predisposing factors. Medicare covers a screening colonoscopy for high-risk beneficiaries every two years.
Coding tip: To bill for a screening colonoscopy for a beneficiary who is not considered high risk for colorectal cancer, use HCPCS code G0121, Baker advises. The code applies to colorectal cancer screening on individuals who do not meet the criteria for high risk.
The Medicare 2001 payment for a screening colonoscopy performed in a hospital or other facility on a patient who is not high risk for colorectal cancer (G0121) is $239.51. This rate will vary slightly by geographic area. Medicare gives the same payment for a screening colonoscopy on a high-risk beneficiary, G0105, and a diagnostic colonoscopy, CPT 45378.
Other new Medicare-covered screening benefits include:
— annual glaucoma screening for people at high risk, a family history of the disease, or with diabetes, effective Jan. 1, 2002;
— medical nutrition therapy by registered dietitians or other qualified nutrition professionals for people with diabetes, chronic renal disease, and post-transplant patients, effective Jan. 1, 2002.
Other preventive services covered by Medicare include:
— four types of colorectal cancer screening tests, including a yearly take-home fecal-occult blood test;
— flexible sigmoidoscopy every four years;
— colonoscopy every two years for high-risk individuals, or a barium enema as an alternative to the colonoscopy or sigmoidoscopy;
— baseline mammogram for women with Medicare aged 35 to 39;
— an annual mammogram for women with Medicare aged 40 and older;
— bone mass measurements for people at risk for osteoporosis;
— prostate cancer screening exams for men with Medicare aged 50 and older (these exams include a digital rectal exam and a Prostate Specific Antigen test annually);
— flu shot each season and a pneumonia shot if needed;
— hepatitis B shot for people with medium to high risk for hepatitis. By law, most of these preventive services require about a 20% co-pay of a Medicare-approved amount. Some, like the annual flu shot (and pneumonia shot when necessary) are free when given by doctors who accept Medicare assignment.
• Diabetes self-management training. Diabetes self-management training is an interactive, collaborative process involving beneficiaries with diabetes and their physicians and instructors. Appropriate training should provide these beneficiaries with the knowledge and skills needed to care for themselves, manage diabetic crises, and make lifestyle changes to manage the disease successfully.
All providers and suppliers who currently bill Medicare for other services, including medical equipment suppliers and kidney dialysis facilities, are qualified to bill for self-management training if they meet all the other requirements. Registered nurses also may be used as part of a multidisciplinary education team instead of certified diabetic educators.
• Diabetic foot care. Beneficiaries with diabetic peripheral neuropathy with loss of protective sensation will be able to receive regular foot care. Medicare will cover two foot exams a year, provided beneficiaries have not seen a foot care professional for some other reason.
• Glaucoma. Medicare now covers annual glaucoma screenings for people with Medicare coverage who are at high risk for contracting the disease.
• Ambulatory blood pressure monitoring. Beneficiaries with suspected "white coat" hypertension — the phenomenon of a person’s blood pressure being higher during a medical exam, perhaps in response to the anxiety of being in the doctor’s office — are now able to receive ambulatory blood pressure monitoring, in which the beneficiary wears a blood pressure cuff over a 24-hour period. The readings are stored in the device and later interpreted in the physician’s office.
• Macular eye degeneration. Medicare has extended coverage of ocular photodynamic therapy with verteporfin to those with "occult lesions." Coverage of the therapy for those with other lesions has already been put in place. However, occult lesions are less well-defined and more difficult to detect. The therapy involves the infusion of a light-activated drug called verteporfin, followed by a laser that activates the drug and treats the adjacent lesions.
• Home testing for blood thinness. Medicare now covers home testing that enables patients with mechanical heart valves to measure how well their blood is thinned. Previously, there had been no national coverage policy for self-testing the prothrombin level in the home (also called INR testing) for patients with mechanical heart valves, and the insurance companies that process and pay Medicare claims had been denying claims for home prothrombin self-testing.
Under local carrier coverage policies, patients receiving home health care could have their prothrombin level measured by home health personnel, and phlebotomists could come to patients’ homes to draw samples to be processed in laboratories. The new national coverage policy allows beneficiaries to perform the test themselves and could permit more frequent monitoring of a patient’s response to blood-thinning medication.
• Liver transplants. Medicare liver transplant coverage now includes certain patients with primary hepatocellular carcinoma (HCC), which is Medicare’s first movement toward transplant coverage for a liver malignancy. CMS is considering the possibility of expanding coverage to other types of malignancies.
A Decision Memorandum dated May 18, 2001, says a patient with primary HCC is eligible for Medicare coverage if the patient is not a liver resection candidate, the patient’s tumor(s) is less than or equal to 5 cm in diameter, there is no macrovascular involvement, and there is no identifiable extrahepatic spread of tumor to surrounding lymph nodes, lungs, abdominal organs, or bone.
• Intestinal transplants. Medicare covers intestinal transplants for beneficiaries with irreversible intestinal failure performed at approved transplant centers, these being the University of Pittsburgh Medical Center, Jackson Memorial Hospital Transplant Center in Miami, and The Mt. Sinai Hospital in New York City.
• Sun-induced skin lesions. CMS expanded Medicare coverage nationally for the treatment of common sun-induced skin lesions, known as actinic keratoses, that can develop into skin cancer. The decision established a national Medicare coverage policy for removing the lesions without restrictions based on lesion or patient characteristics. Previously, some Medicare carriers had local policies that restricted coverage to specific lesion types (such as those located on specific parts of the body) or in certain patients (such as those with a prior history of skin cancer).