(Medicare Claims Processing Manual)

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   Group Code: CO assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file).    NOTE:  For modifier GZ, use CARC 50 and MSN 8.81.         220.5  Common Working File (CWF) Edits  (Rev. 11388, Issued:04- 29, 22; (Effective:02 -10-22; Implementation:10 -03-22)   The common working file (CWF) shall apply the following limitations to lung cancer screening with LDCT:   Allow one HCPCS code 71271 per annum. At least 11 full months must elapse from the date of the last screening. NOTE:   This edit shall be overridable.   Reject HCPCS codes G0296 and 71271 claims lines for beneficiaries that are not between the ages of 50 and 77 (55 and 77 for DOS prior to February 10, 2022).  NOTE : Effective December 31, 2020, HCPCS code G0297 is end- dated and replaced with 71271.  230  Screening for Hepatitis B Virus (HBV)  (Rev. 3831, Issued: 08- 04-17, Effective: 09 -28-16, Implementation: 10 - 02- 17, October 2, 2017 - analysis and design; January 2, 2018 -  testing and implementation)   Effective for services furnished on or after September 28, 2016, an initial screening for hepatitis B virus infection (HBV) is covered for asymptomatic, non -pregnant adolescents and adults at high risk for HBV infection. High risk is defined as persons born in countries and regions with high prevalence of HBV infection (i.e.,  2%), US -born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection (i.e.,  8%), HIV -positive persons, men who have sex with men, injection drug users, household contacts or sexual partners of persons with HBV infection.   In addition, CMS has determined that repeated screening would be appropriate annually only for beneficiaries with continued high risk (men who have sex with men, injection drug users, household contacts or sexual partners of persons with HBV infection) who do not receive hepatitis B vaccination.   A screening test at the first prenatal visit is covered for pregnant women and then rescreening at time of delivery for those with new or continuing risk factors. In addition, CMS has determined that screening during the first prenatal visit would be appropriate for each pregnancy, regardless of previous hepatitis B vaccination or previous negative hepatitis B surface antigen (HBsAg) test results. See section 170 of this chapter for coverage and billing instructions for pregnant beneficiaries.   Effective for claims with dates of service on or after September 28, 2016, the claims processing instructions for payment of screening for hepatitis B virus will apply to the following HCPCS and CPT codes:    HBV screening for asymptomatic, non- pregnant adolescents and adults at high risk -  code G0499    HBV screening for pregnant women  CPT codes 86704, 86706, 87340 and 87341  A. Frequency   HBV screening for asymptomatic, non -pregnant adolescents and adults at high risk (HCPCS code G0499)    A single, one -time screening test is covered for asymptomatic, non pregnant adolescents and adults who do meet the high risk definition above.    Repeat screening for high risk persons is covered annually only for persons who have continued high risk who do not receive hepatitis B vaccination .    Note: Annual means a full 11 months must elapse following the month in which the previous negative screening took place.   Note for ESRD:  Effective for claims with dates of service on or after September 28, 2016 submitted with G0499  HepB screen high risk indiv, for asymptomatic non- pregnant beneficiaries and ICD -10 diagnosis code N18.6, End Stage Renal Disease, all of the  preceding requirements shall be bypassed and the claim shall be allowed to pay, no matter what other ICD -10 diagnosis codes may appear on the claim.    HBV screening for pregnant women (CPT codes 86704, 86706, 87340 and 87341)    One occurrence per pregnancy of screening for HBV in pregnant women, and   One additional occurrence per pregnancy of screening for HBV in pregnant women who are at continued risk  B. Determination of High Risk for Hepatitis B Disease   The determination of high risk for HBV is identified by the primary care physician or practitioner who assesses the patients history, which is part of any complete medical history, typically part of an annual wellness visit, and considered in the development of a comprehensive prevention plan.  The medical record should be a reflection of the service provided.   Note: See Pub. 100- 03, Medicare National Coverage Determinations (NCD) Manual 210.6 for complete coverage guidelines.   230.1  Institutional Billing Requirements  (Rev. 3831, Issued: 08- 04-17, Effective: 09 -28-16, Implementation: 10-  02- 17, October 2, 2017 - analysis and design; January 2, 2018 -  testing and implementation)   Effective for claims with dates of service on or after September 28, 2016, providers may use the following types of bill (TOBs) when submitting claims for HBV screening, HCPCS G0499, 86704, 86706, 87340, and 87341: 13X, 14X, 72X, and 85X.  Deductible and c oinsurance do not apply. Service line -items on other TOBs shall be denied.  The service shall be paid on the basis shown below:    Outpatient hospitals  TOB 13X -  based on Outpatient Prospective Payment System   Non-patient laboratory specimen  TOB 14X  based on laboratory fee schedule   End Stage Renal Disease facilities (ESRDs)  TOB 72X  based on ESRD PPS when submitted with code G0499 and diagnosis code N18.6. HBV is not separately payable for (ESRD TOB 72X)  unless reported with Modifier AY.   Critical Access Hospitals (CAHs) -  TOB 85X  based on reasonable cost when the revenue code is not 096X, 097X, and 098X  Note: For outpatient hospital settings, as in any other setting, services covered under this NCD must be provided by a primary care provider.  NOTE : Beneficiary coinsurance and deductibles do not apply to claim lines containing HCPCS G0499, and CPT codes 86704, 86706, 87340, and 87341. NOTE:   Medicare Administrative Contractors shall contractor -price HBV screening claims, HCPCS G0499, with dates of service September 28, 2016 through December 31, 2017.   230.2  Professional Billing Requirements  (Rev. 3831, Issued: 08- 04-17, Effective: 09 -28-16, Implementation: 10-  02- 17, October 2, 2017 - analysis and design; January 2, 2018 -  testing and implementation)   For claims with dates of service on or after September 28, 2016, CMS will allow coverage for HBV screening, CPT codes 86704, 86706, 87340, 87341, and HCPCS G0499, only when services are ordered by the following provider specialties found on the providers enrollment record:   01 - General Practice  08 - Family Practice  11 - Internal Medicine  16 - Obstetrics/Gynecology 37 - Pediatric Medicine  38 - Geriatric Medicine  42  Certified Nurse Midwife  50 - Nurse Practitioner  89 - Certified Clinical Nurse Specialist 97 - Physician Assistant   Claims ordered by providers other than the specialty types noted above will be denied.   For claims with dates of service on or after September 28, 2016, CMS will allow coverage for HBV screening, 86704, 86706, 87340, 87341, and  G0499, only when submitted with one of the following place of service (POS) codes:   11  Physicians Office  19- Off Campus Outpatient Hospital  22  On Campus Outpatient Hospital  49  Independent Clinic  71  State or Local Public Health Clinic  81-Independent Laboratory Claims submitted without one of the POS codes noted above will be denied.   NOTE : Beneficiary coinsurance and deductibles do not apply to claim lines containing CPT codes 86704, 86706, 87340, 87341, and HCPCS G0499.   NOTE:   Medicare Administrative Contractors shall contractor -price HBV screening claims, HCPCS G0499, with dates of service September 28, 2016 through December 31, 2017.   230.3  Diagnosis Code Reporting Requirements  (Rev.11035, Issued:10 -13-21, Effective: 11-17-21; Implementation:  11-17-21) For claims with dates of service on or after September 28, 2016, CMS will allow  coverage for HBV screening, HCPCS G0499, only when services are reported with both of  the following diagnosis codes denoting high risk:  Z11.59 Encounter  for screening  for other  viral  disease,  and, Z72.89 Other  Problems  related  to life style   For claims with dates of service on or after September 28, 2016, CMS will allow  coverage for HBV  screening,  HCPCS  G0499, for subsequent  visits  only when  services  are reported with the  following diagnosis codes:   Z11.59, and,  one of the high risk diagnosis  codes  below: