(Medicare Claims Processing Manual)

Short Descriptor:   Ultrasound exam AAA screen   Modifiers:   TC, 26   Effective for services furnished on or after January 1, 2017, the following code and modifiers, are used for AAA screening services:   76706: Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA).  (For screening ultrasound or duplex ultrasound of the abdominal aorta other than screening, see 76770, 76775, 93978, 93979.)   Short Descriptor:   Us abdl aorta screen AAA   Modifiers:   TC, 26   110.3.3 - Advance Beneficiary Notice  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  A/B MACs (A) and (B) will deny an AAA screening service billed more than once in a beneficiarys lifetime.   If a second AAA ultrasound screening is billed for the same beneficiary or if any of the other statutory criteria for coverage listed in section 1861(s)(2)(AA) of the Social Security Act are not met, the service would be denied as a statutory (technical) d enial under section 1861(s)(2)(AA), not a medical necessity denial.  If a provider cannot determine whether or not the beneficiary has previously had an AAA screening, but all of the other statutory requirements for coverage have been met, the provider should issue the ABN -G.  Likewise, if all of the statutory requirements for coverage have been met, but a question of medical necessity still exists, the provider should issue the ABN -G.  110.3.4 - RHCs/FQHCs Special Billing Instructions  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  Detailed billing instructions for ultrasound screening for AAA screenings provided in RHCs and FQHCs can be found in chapter 9, section 70.3 of this manual.  120 - Diabetes Self -Management Training (DSMT) Services (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, section 300 for information on coverage requirements, certified providers and enrollment.  120.1 - Coding and Payment of DSMT Services  (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The following HCPCS codes are used to report DSMT:    G0108 -  Diabetes outpatient self -management training services, individual, per 30 minutes.   G0109 -  Diabetes outpatient self -management training services, group session (2 or more), per 30 minutes.   The type of service for these codes is 1.   Payment to physicians and providers for outpatient DSMT is made as follows:   Type of Facility Payment Method  Type of Bill  Physician (billed to the A/B MAC (B))  MPFS  NA Hospitals subject to OPPS  MPFS  12X, 13X  Method I and Method II Critical Access Hospitals (CAHs) (technical services)  101% of reasonable cost  12X and 85X  Indian Health Service (IHS) providers billing hospital outpatient Part B  OMB -approved outpatient per visit all inclusive rate (AIR)  13X IHS providers billing inpatient Part B  All-inclusive inpatient ancillary per diem rate  12X IHS CAHs billing outpatient Part B  101% of the all -inclusive facility specific per visit rate  85X IHS CAHs billing inpatient Part B  101% of the all -inclusive facility specific per diem rate  12X FQHCs*  All-inclusive encounter rate with other qualified services. Separate visit payment available with HCPCS.  73X Skilled Nursing Facilities **  MPFS non- facility rate  22X, 23X  Maryland Hospitals under jurisdiction of the Health Services Cost Review Commission (HSCRC)  94% of provider submitted charges in accordance with the terms of the Maryland Waiver  12X, 13X  Home Health Agencies (can be billed only if the service is provided outside of the treatment plan)  MPFS non- facility rate  34X  * Effective January 1, 2006, payment for DSMT provided in an FQHC that meets all of the requirements as above, may be made in addition to one other visit the beneficiary had during the same day, if this qualifying visit is billed on TOB 73X, with HCPCS G0108 or G0109, and revenue codes 0520, 0521, 0522, 0524, 0525, 0527, 0528, or 0900.  ** The SNF consolidated billing provision allows separate part B payment for training services for beneficiaries that are in skilled Part A SNF stays, however, the SNF must submit these services on a 22 bill type.  Training services provided by other provi der types must be reimbursed by X the SNF.   NOTE:  An ESRD facility is a reasonable site for this service, however, because it is required to provide dietician and nutritional services as part of the care covered in the composite rate, ESRD facilities are not allowed to bill for it separately and do not re ceive separate reimbursement.  Likewise, an RHC is a reasonable site for this service, however it must be provided in an RHC with other qualifying services and paid at the all -inclusive encounter rate.   Deductible and co -insurance apply.   120.2 - Bill Processing Requirements (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  See Pub. 100- 04, chapter 25 for instructions for A/B MACs (A) and (HHH).  See Pub. 100- 04, chapter 26 for instructions for A/B MACs (B).  Billing is to the "certified providers" regular A/B MAC (A), (B), or (HHH), i.e., there are no specialty contractors for this service.  (See Pub 100- 02, chapter 15, section 300.2 for the definition of certified provider in this instance.)   120.2.1 - Special Processing Instructions for Billing Frequency Requirements  (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The frequency editing for DSMT is performed in CWF as follows:   A - Initial Training   The initial year for DSMT is the '12' month period following the initial date.  When a claim contains a DSMT HCPCS code and the associated units cause the total time for the DSMT initial year to exceed '10' hours, a CWF error will set.   See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, section 300 for information on coverage for initial training.  B - Follow -Up Training   Follow -up training for subsequent years are based on a 12 month calendar year after the initial year.  However, if the beneficiary exhausts 10 hours in the initial year then the beneficiary would be eligible for follow -up training in the next calendar year.  When a claim contains a DSMT HCPCS code and the associated units cause the total time for any follow -up year to exceed 2 hours, a CWF error will set.  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, section 300 for information on coverage for follow -up training.   C - Examples   Example # 1 -- Beneficiary Exhausts 10 hours in the Initial Year (12 continuous months)   Bene receives first service: April, 2006 Bene completes initial 10 hours DSMT training:  April, 2007 Bene is eligible for follow -up training: May 2007 (13th month begins the subsequent year)  Bene completes follow -up training: December, 2007 Bene is eligible for next year follow -up training:  January, 2008   Example # 2 Beneficiary Exhausts 10 hours Within the Initial Calendar Year   Bene receives first service: April 2006  Bene completes initial 10 hours of DSMT training, December 2006  Bene is eligible for follow -up training: January, 2007 Bene completes follow -up training:  July 2007 Bene is eligible for next year follow -up training: January 2008   120.2.2 - Advance Beneficiary Notice (ABN) Requirements  (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The beneficiary is liable for services denied over the limited number of hours with referrals for DSMT.  An ABN should be issued in these situations.  In absence of evidence of a valid ABN, the provider will be held liable.   An ABN should not be issued for Medicare -covered services such as those provided by hospital dietitians or nutrition professionals who are qualified to render the service in their State but who have not obtained Medicare Provider Numbers.   120.2.3 - RHCs/FQHCs Special Billing Instructions  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  Detailed billing instructions for DSMT services provided in RHCs and FQHCs can be found in chapter 9, section 70.5 of this manual.  120.3 - Duplicate Edits  (Rev. 1846; Issued: 11- 06-09; Effective Date:  04 -01-10; Implementation Date:  04- 05-10)  There are CWF edits applicable to DSMT. Refer to chapter 4, section 300.6 of this manual for a description of these instructions.  130 - Human Immunodeficiency Virus (HIV) Screening Tests  (Rev.  3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17)   130.1 - Healthcare Common Procedure Coding System (HCPCS) for HIV Screening Tests  (Rev.  3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17)   Effective for claims with dates of service on and after December 8, 2009, implemented with the April 5, 2010, IOCE, the following HCPCS codes are to be billed for human immunodeficiency virus (HIV) screening:    G0432-  Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV -1 and/or HIV-2, screening,    G0433 -  Infectious agent antibody detection by enzyme -linked immunosorbent assay (ELISA) technique, HIV -1 and/or HIV -2, screening, and,    G0435 -  Infectious agent antibody detection by rapid antibody test, HIV -1 and/or HIV -2, screening.  In addition to the above codes,  effective for claims with dates of service on or after April 13, 2015, the following HCPCS/CPT code may also be billed for HIV screening:    G0475 -   HIV antigen/antibody, combination assay, screening  80081 -   Obstetric panel   130.2 - Billing Requirements (Rev.  3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17) Medicare Administrative Contractors (MACs) shall recognize the above HCPCS codes for HIV screening in accordance with Publication 100- 03, Medicare National Coverage Determinations Manual, section 210.7.  Effective for claims with dates of service on and after December 8, 2009, MACs shall pay for voluntary HIV screening as follows :   A maximum of once annually for beneficiaries at increased risk for HIV infection (11 full months must elapse following the month the previous test was performed in order for the subsequent test to be covered), and,    A maximum of three times per term of pregnancy for pregnant Medicare beneficiaries beginning with the date of the first test when ordered by the womans clinician.   Claims that are submitted for HIV screening shall be submitted in the following manner:   For beneficiaries reporting increased risk factors, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 (Special screening for other specified viral disease) as primary, and V69.8 (Other problems related to lifestyle), as seco ndary.