(Medicare Claims Processing Manual)

WAIVED   Annual Wellness  Visit   G0438  Annual  wellness  visit, including PPPS, first visit  *Not Rated   WAIVED   G0439  Annual  wellness  visit, including PPPS, subsequent visit   WAIVED   Intensive Behavioral   G0447  Face -to-Face Behavioral Counseling for Obesity, 15 minutes   B  WAIVED  Therapy  for Obesity   G0473  Face -to-face behavioral counseling for obesity, group  (2-10), 30 minute(s)     Lung  Cancer Screening   G0296  Counseling  visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)   B      WAIVED   G0297  Low dose CT scan (LDCT) for lung cancer screening  COVID -19 Vaccine   See link https://www.cms.g ov/medi care/medicare -part-b-drug-  average -sales -price/covid - 19-vaccines -and- monoclonal -antibodies       WAIVED   1.3 - Waiver of Cost Sharing Requirements of Coinsurance, Copayment and Deductible for Furnished Preventive Services Available in Medicare  (Rev. 2233, Issued: 05- 27-11, Effective: 01 -01-11, Implementation: 06- 28-11)  Section 4104(b)(4) of the ACA, amends section 1833(a)(1) of the Act, by requiring 100 percent payment for the IPPE, AWV and for those preventive services recommended by the United States Preventive Services Task Force (USPSTF) with a grade of A or B for any indication or population and that are appropriate for the indi vidual.  Waiver of Coinsurance and Copayment for Preventive Services and Screenings   This requirement waives any coinsurance or copayment that would otherwise be applicable under section 1833(a)(1) of the Act for those items and services listed in section 1861(ww)(2) of the Act (excluding electrocardiograms) to which the USPSTF has given a grade of A or B.  In addition, section 4103(c)(1) of the Affordable Care Act waives the coinsurance or copayment for the AWV.   The coinsurance or copayment represents the beneficiarys share of the payment to the provider or supplier for furnished services.  Coinsurance generally refers to a percentage (for example, 20 percent) of the Medicare payment rate for which the beneficiar y is liable and is applicable under the PFS, while copayment generally refers to an established amount that the beneficiary must pay that is not necessarily related to a particular percentage of the Medicare payment, and is applicable under the hospital Outpatient Prospective Payment System (OPPS).   Waiver of Deductible for Preventive Services and Screening   Section 4104(b)of the Affordable Care Act amends section 1833(b)(1) of the Act to waive the deductible for preventive services described in subparagraph (A) of section 1861(ddd)(3) of the Act that have a grade of A or B from the USPSTF.  In addition, secti on 4103(c)(1) of the Affordable Care Act waives the deductible for the AWV.  These provisions are effective for services furnished on and after January 1, 2011.  Section 101(b)(2) of the MIPPA amended section 1833(b) of the Act to waive the deductible for the IPPE effective January 1, 2009.   NOTE:   Not all preventive services allowed in Medicare and recommended by the USPSTF have a Grade of A or B, and therefore, some of the preventive services do not meet the criteria in sections 1833(a)(1) and (b)(1) of the Act for the waiver of deductible and coinsurance.  Refer to the Preventive Services Table in section 5.2, of this section, for specific USPSTF ratings for preventive services.   10 - Pneumococcal Pneumonia, Influenza Virus, Hepatitis B, and Coronavirus Disease (COVID -19) Vaccines and Administration                                                                             (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  For MACs (Part B), Part B of Medicare pays 100 percent of the Medicare allowed amount for pneumococcal, influenza, hepatitis B virus COVID -19 vaccines and their administration.   Part B deductible and coinsurance do not apply for pneumococcal, influenza, hepatitis virus and/or COVID- 19 vaccine.   State laws governing who may administer preventive vaccinations and the coronavirus vaccines as well as how the vaccines are transported vary widely.  Medicare contractors should instruct physicians, suppliers, and providers to become familiar with state r egulations for all vaccines in the areas where they will be immunizing.   10.1 - Coverage Requirements  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)   Pneumococcal, influenza virus, hepatitis B, and COVID -19 vaccines and their administration are covered only under Medicare Part B, regardless of the setting in which they are furnished, even when provided to an inpatient during a hospital stay covered unde r Part A.   See Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, for additional coverage requirements for pneumococcal, hepatitis B, influenza virus, and COVID -19 vaccinations.   10.1.1 -  Pneumococcal Vaccine  (Rev. 3159, Issued: 12- 31-14, Effective: 09 -19-14, Implementation: 02- 02-15)  Section 1861(s)(10)(A) of the Social Security Act and regulations at 42 CFR 410.57 authorize Medicare coverage under Part B for pneumococcal vaccine and its administration.  Medicare does not require for coverage purposes, that a doctor of medicine or oste opathy order the pneumococcal vaccine and its administration.  Therefore, the beneficiary may receive the vaccine upon request without a physicians order and without physician supervision.   See Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 50.4.4.2 for complete coverage requirements for pneumococcal vaccine.   10.1.2 - Influenza Virus Vaccine  (Rev. 2253, Issued: 07- 08-11, Effective: 08 -08-11, Implementation: 08- 08-11)  Effective for services furnished on or after May 1, 1993, the influenza virus vaccine and its administration is covered when furnished in compliance with any applicable State law.  Typically, this vaccine is administered once a flu season.  Medicare does n ot require for coverage purposes that a doctor of medicine or osteopathy order the vaccine.  Therefore, the beneficiary may receive the vaccine upon request without a physicians order and without physician supervision.  Since there is no yearly limit, A/B  MACs (A) and (B) determine whether such services are reasonable and allow payment if appropriate.   See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.4.2 for additional coverage requirements for influenza virus vaccine.   10.1.3 - Hepatitis B Vaccine  (Rev. 1, 10- 01-03)  Effective for services furnished on or after September 1, 1984, the hepatitis B vaccine and its administration is covered if it is ordered by a doctor of medicine or osteopathy and is available to Medicare beneficiaries who are at high or intermediate risk  of contracting hepatitis B, e.g., exposed to hepatitis B.   See the Medicare Benefit Policy Manual, Chapter 15, for additional coverage requirements for hepatitis B vaccines to high risk and intermediate risk groups.  10.1.4  COVID -19 Vaccine  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  The COVID -19 vaccine and its administration are covered when furnished in compliance with any applicable State law.  Effective dates for each COVID -19 vaccine can be found at https://www.cms.gov/medicare/medicare -part-b-drug-average -sales -price/covid -19-vaccines -and-monoclonal -antibodies .   The COVID -19 vaccine is administered according to manufacturers recommendations for each specific vaccine during the public health emergency declared in 2020. This recommendation is subject to change.     10.2 - Billing Requirements (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  A.  Edits Not Applicable to Claims for Pneumococcal, Influenza, or COVID -19 Vaccines and Administration   The Common Working File (CWF) and shared systems bypass all Medicare  Secondary Payer (MSP) utilization edits in CWF on all claims when the only service provided  is pneumococcal, influenza, or COVID -19 vaccine and/or their administration.  This waiver  does not apply when other services, (e.g., office visits), are billed on the same claim  as pneumococcal, influenza virus, or COVID -19 virus vaccinations.  If the provider knows, or has reason to believe that a particular group health plan covers preventive vaccines and their administration, and all ot her MSP requirements for the  Medicare beneficiary are met, the primary payer must be billed.   First claim development alerts from CWF are not generated for pneumococcal, influenza virus or COVID- 19 vaccine.  However, first claim development is performed if  other services are submitted along with pneumococcal, influenza virus, or COVID -19 vaccines.   See Pub. 100- 05, Medicare Secondary Payer Manual, chapters 4 and 5, for responsibilities for MSP development where  applicable.   B  Institutional  Claims   Chapter 25 of this manual provides general billing instructions that must be followed for institutional claims.   The following providers of services may administer and submit institutional claims  to the A/B MACs (A) for these  vaccines:   Hospitals;  Critical Access Hospitals  (CAHs);  Skilled Nursing Facilities  (SNFs);  Home Health Agencies  (HHAs);  Hospices;  Comprehensive Outpatient Rehabilitation Facilities (CORFs); and  Indian Health Service (IHS)/Tribally owned and/or operated hospitals  and hospital -based  facilities.  Other billing entities that may submit institutional claims  are:  Independent Renal Dialysis Facilities  (RDFs).  All providers submit institutional claims for hepatitis B. Providers other  than independent RHCs and freestanding FQHCs submit institutional claims for  influenza virus, COVID -19 vaccines and pneumococcal vaccinations.  (See 10.2.2.2 of this chapter for  special instructions for independent RHCs and freestanding FQHCs.)   Institutional providers, other than independent RHCs and freestanding FQHCs, should bill for the vaccines and their administration on the same bill.  Separate bills for  vaccines and their administration are not required.  The only exceptions to this rule occur when the vaccine is administered during the course of an otherwise covered home health visit  since the vaccine or its administration is not included in the visit charge. (See 10.2.3 of  this chapter).   C  Professional  Claims   Billing for Additional  Services   If a physician sees a beneficiary for the sole purpose of administering a Medicare covered preventive vaccine, they may  not routinely bill for an office visit.  However, if the beneficiary actually receives  other  services constituting an office visit level of service, the physician may bill for a visit  in addition to the vaccines and their administration, and Medicare will pay for the visit  in addition to the vaccines and their administration if it is reasonable and medically necessary.   Nonparticipating Physicians and Suppliers   Nonparticipating physicians and suppliers (including local health facilities) that do not accept assignment may collect payment from the beneficiary for the administration of  the vaccines, but must submit an unassigned claim on the beneficiarys behalf.  Effective  for claims with dates of service on or after February 1, 2001, per 114 of the  Benefits Improvement and Protection Act of 2000, all drugs and biologicals must be paid based  on mandatory assignment.  Therefore, regardless of whether the physician and supplier usually accept assignment, they must accept assignment for the vaccines, may not  collect any fee up front, and must submit the claim for the  beneficiary.   Entities, such as local health facilities, that have never submitted Medicare claims  must obtain a National Provider Identifier (NPI) for Part B billing  purposes.   Separate Claims for Vaccines and Their  Administration