(Medicare Claims Processing Manual)

High Risk Diagnosis Codes   ICD-10-CM codes   Description  Z77.9  Other contact with and (suspected) exposures hazardous to health  Z77.29  Contact with and (suspected) exposure to other hazardous substances  Z72.51  High risk heterosexual behavior  Z72.52  High risk homosexual behavior  Z72.53  High risk bisexual behavior  Z91.89  Other specified personal risk factors, not elsewhere classified  Z92.850  Personal history of Chimeric Antigen Receptor T -cell therapy  Z92.858  Personal history of other cellular therapy  Z92.86  Personal history of gene therapy  Z92.89  Personal history of other medical treatment   A. Applicable Diagnoses for Billing an A/B MAC (B)   For professional claims, providers report diagnosis codes according to the instructions in the ASC X12 837 professional claim technical report 3 for electronic claims and chapter 26 of this manual for paper claims.  Part of this reporting includes pointing (relating) the claimed service to a diagnosis code on the claim.  There are a number of appropriate diagnosis codes that can be used in billing for screening pelvic examinations that the provider can list on the claim to give a true picture of the patients condition.  In addition, one of the diagnoses listed in either t he high risk or low risk tables above (40.4) must be on the claim to indicate either low risk or high risk depending on the patients condition, and the screening pelvic examination service must point to this diagnosis code.  Providers must make sure that, for screening pelvic exams for a high risk beneficiary, a high risk diagnosis code appears on the claim and that the screening pelvic examination service points to this diagnosis code.  If pelvic examination claims do not point to one of these specific diagnoses, the claim will reject in the CWF.  If these pointers are not present on claims submitted to A/B MACs (B), CWF will reject the record.   Periodically, A/B MACs (B) should do provider education on diagnosis coding of screening pelvic examination claims.   B. Applicable Diagnoses for Billing an A/B MAC (A)   For institutional claims, providers report diagnosis codes according to the instructions in the ASC X12 837 institutional claim technical report 3 for electronic claims and chapter 25 of this manual for paper claims.  (Chapter 25 also contains additional general billing information for institutional claims.)   Appropriate diagnoses are shown above in this section for low risk and high risk beneficiaries.   Periodically provider education should be done on diagnosis coding of screening pelvic exam claims.    40.5 - Payment Method  (Rev 440, Issued: 01- 21-05, Effective: 07 -01-05, Implementation: 07- 05-05)  Pelvic examinations are paid under the MPFS, whether billed to the A/B MAC (A) or (B) except :   Hospital outpatient services are paid under OPPS;    See 40.5.B  of this chapter for proper billing by RHC/FQHCs for the professional and technical components of a screening pelvic examination.  RHCs/FQHCs are paid under the all-inclusive rate for the professional component; or based on the providers payment method for the technical component;    CAH payment is under reasonable cost.  NOTE:   SNFs are paid under the MPFS and bill the A/B MAC (A).  Physicians and other individual practitioners bill the A/B MAC (B).   40.6 - Revenue Code and HCPCS Codes for Billing  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A. Billing to the A/B MAC (B)   Code G0101 (cervical or vaginal cancer screening, pelvic and clinical breast examination) is used.   Effective for services on or after January 1, 1999, a covered evaluation and management (E/M) visit and code G0101 may be reported by the same physician for the same date of service if the E/M visit is for a separately identifiable service.  In this case, the modifier  -25 must be reported with the E/M service and the medical reco rds must clearly document the E/M service reported.  Both procedure codes should be shown as separate line items on the claim.  These services can also be performed separately on separate office visits.   B. Billing to the A/B MAC (A)   The applicable bill types for a screening pelvic examination (including breast examination) are 12X, 13X, 22X, 23X, and 85X.  The applicable revenue code is 0770.  (See 70.1.1.2 for RHCs and FQHCs.)  Effective April 1, 2006, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for a screening pelvic examination.  The professional component of a screening pelvic examination furnished within an RHC/FQHC by a physician or nonphysician is considered an RHC/FQHC service.  RHCs and FQHCs bill the A/B MAC (A) under bill type 71X or 73X for the professional component along with revenue code 052X.  The technical component of a screening pelvic examination is outside the scope of the RHC/FQHC benefit.  If the technical component of this service is furnished within an independent RHC or freestanding FQHC, the provider of that technical service bills the A/B MAC (B) on the ASC X12 837 professional claim format or hardcopy Form CMS -1500.  If the technical component of a screening pelvic examination is furnished within a provider -based RHC/FQHC, the provider of that service bills the A/B MAC (A) under bill type 12X, 13X, 22X, 23X, or 85X as appropriate using their outpatient provider number (not the RHC/FQHC provider number since these services are not covered as RHC/FQHC services).  The appropriate revenue code is 0770.  Effective April 1, 2006, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for a screen ing pelvic examination.  40.7 - MSN Messages (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  If there are no high risk factors, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, A/B MACs (A) and (B) use MSN 18.17:    Medicare pays for a screening Pap smear and/or screening pelvic examination only once every (2, 3) years unless high risk factors are present.  40.8 - Remittance Advice Codes (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  If high risk factors are not present, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, use existing ASC X12 835:    Claim adjustment reason code 119 -  Benefit maximum for this time period has been reached  at the line level, and    Remark code M83 - Service is not covered unless the patient is classified as at high risk at the line item level.   50 - Prostate Cancer Screening Tests and Procedures  (Rev. 1, 10- 01-03)  B3-4182, A3- 3616   Sections 1861(s)(2)(P) and 1861(oo)  of the Act (as added by 4103 of the Balanced Budget Act of 1997), provide for Medicare Part B coverage of certain prostate cancer screening tests subject to certain coverage, frequency, and payment limitations.  Effective for services furnished on or aft er January 1, 2000, Medicare Part B covers prostate cancer screening tests/procedures for the early detection of prostate cancer.  Coverage of prostate cancer screening tests includes the following procedures furnished to an individual for the early detect ion of prostate cancer:    Screening digital rectal examination, and   Screening prostate specific antigen (PSA) blood test.  Each test may be paid at a frequency of once every 12 months for men who have attained age 50 (i.e., starting at least one day after they have attained age 50), if at least 11 months have passed following the month in which the last Medicare -covered screening digital rectal examination was performed (for digital rectal exams) or PSA test was performed (for PSA tests).   50.1 - Definitions  (Rev. 1, 10- 01-03) A3-3616.A.1 and 2  A. Screening Digital Rectal Examination   Screening digital rectal examination means a clinical examination of an individuals prostate for nodules or other abnormalities of the prostate.  This screening must be performed by a doctor of medicine or osteopathy (as defined in 186l(r)(1)  of the Act), or by a physician assistant, nurse practitioner, clinical nurse specialist, or by a certified nurse mid -wife (as defined in 1861(aa)  and 1861(gg)  of the Act), who is authorized under State law to perform the examination, fully knowledgeable about the beneficiary, and would be responsible for explaining the results of the examination to the beneficiary.   B. Screening Prostate Specific Antigen (PSA) Tests   Screening prostate specific antigen (PSA) is a test that measures the level of prostate specific antigen in an individuals blood.  This screening must be ordered by the beneficiarys physician or by the beneficiarys physician assistant, nurse practitione r, clinical nurse specialist, or certified nurse midwife (the term physician is defined in 1861(r)(1)  of the Act to mean a doctor of medicine or osteopathy and the terms physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife are defined in 1861(aa) and 1861(gg) of the Act) who is fully knowledgeable about the beneficiary, and who would be responsible for explaining the results of the test to the beneficiary.   50.2 - Deductible and Coinsurance  (Rev. 1, 10- 01-03)  B3-4182.3  The screening PSA test is a lab test to which neither deductible nor coinsurance apply. Both deductible (if unmet) and coinsurance are applicable to screening rectal examinations.   50.3 - Payment Method - A/B MACs (A) and (B)  (Rev. 11902; Issued:03- 16-23; Effective: 04 -17-23; Implementation: 04 -17-23)  Screening PSA tests (G0103) are paid under the clinical diagnostic lab fee schedule.   Screening PSA tests (Effective 01/01/23 (0359U)) new codes are contractor -priced (where applicable) until they are nationally priced and undergo the CLFS annual payment determination process.  Screening rectal examinations (G0102) are paid under the MPFS except for the following bill types identified (A/B MAC (A) only).  Bill types not identified are paid under the MPFS.  12X = Outpatient Prospective Payment System  13X = Outpatient Prospective Payment System  14X-=Outpatient Prospective Payment System  71X = Included in All Inclusive Rate  73X = Included in All Inclusive Rate  85X = Cost (Payment should be consistent with amounts paid for code 84153 or code 86316.)   Effective 4/1/06 the type of bill 14X is for non- patient laboratory specimens.   The RHCs and FQHCs should include the charges on the claims for future inclusion in encounter rate calculations.   50.3.1 - Correct Coding Requirements for A/B MAC (B)  Claims  (Rev. 1, 10- 01-03)  B3-4182.6  Billing and payment for a Digital Rectal Exam (DRE) (G0102) is bundled into the payment for a covered E/M service (CPT codes 99201 -  99456 and 99499) when the two services are furnished to a patient on the same day.  If the DRE is the only service or is pr ovided as part of an otherwise noncovered service, HCPCS code G0102 would be payable separately if all other coverage requirements are met.   50.4 - HCPCS, Revenue, and Type of Service Codes  (Rev. 11902; Issued:03- 16-23; Effective: 04 -17-23; Implementation: 04 -17-23)  The appropriate bill types for billing the A/B MAC (A) on Form CMS -1450 or its electronic equivalent are 12X, 13X, 14X, 22X, 23X, 71X, 73X, 75X, and 85X.  Effective 4/1/06, type of bill 14X is for non- patient laboratory specimens.   The HCPCS code G0102 -  for prostate cancer screening digital rectal examination.    A/B MAC (B) TOS is 1    A/B MAC (A) revenue code is 0770