(Medicare Claims Processing Manual)

100 - Cardiovascular Disease Screening  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01 -03-05)  100.1 - HCPCS Coding for Cardiovascular Disease Screening  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01- 03-05)  The following HCPCS codes are to be billed for Cardiovascular Disease Screening:   80061 -  Lipid Panel  82465 -  Cholesterol, serum or whole blood, total  83718 -  Lipoprotein, direct measurement, high density cholesterol  84478 -  Triglycerides   100.2 - A/B MAC (B) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service, January 1, 2005, and later, A/B MACs (B) shall recognize the above HCPCS codes for Cardiovascular Disease Screening.   A/B MACs (B) shall pay for Cardiovascular Disease Screening once every 60 months.  A claim that is submitted for Cardiovascular Disease Screening shall be submitted in the following manner:   The line item shall contain 80061, 82465, 83718 or 84478 with one of the following diagnoses:   If ICD -9-CM is applicable  V81.0 -  Special screening for ischemic heart disease,  V81.1 -  Special screening for hypertension or  V81.2 -  Special screening for other and unspecified cardiovascular conditions   If ICD -10-CM is applicable  Z13.6 -  encounter for screening for cardiovascular disease   The appropriate diagnosis codes are reported in the header and pointed to the line item.  100.3 - A/B MAC (A) Billing Requirements (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service, January 1, 2005, and later, A/B MACs (A)  shall recognize the above HCPCS codes for Cardiovascular Disease Screening.   A/B MACs (A) shall pay for Cardiovascular Disease Screening once every 60 months.  A claim that is submitted for Cardiovascular Disease Screening shall be submitted in the following manner:   The line item shall contain 80061, 82465, 83718 or 84478 with one of the following diagnosis codes reported in the header:   If ICD -9-CM is applicable  V81.0 -  Special screening for ischemic heart disease,  V81.1 -  Special screening for hypertension or  V81.2 -  Special screening for other and unspecified cardiovascular conditions   If ICD -10-CM is applicable  Z13.6 -  encounter for screening for cardiovascular disease   100.4 - Diagnosis Code Reporting  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A claim that is submitted for Cardiovascular Disease Screening shall be submitted with one or more of the following diagnosis codes in the header and pointed to the line item:   If ICD -9-CM is applicable  V81.0 -  Special screening for ischemic heart disease,  V81.1 -  Special screening for hypertension, or  V81.2 -  Special screening for other and unspecified cardiovascular conditions   If ICD -10-CM is applicable  Z13.6 -  encounter for screening for cardiovascular disease   100.5 - Medicare Summary Notice  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  When denying claims for cardiovascular screening based upon a CWF reject for 80061, 82465, 83718, or 84478 billed with one or more the of the following diagnosis codes , A/B MACs (A) and (B) shall use MSN 16.54 Medicare does not pay for this many services or supplies.  ICD- 9-CM V81.0, V81.1 or V81.2,   ICD- 10-CM Z13.6  100.6 - Remittance Advice Remark Codes  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01- 03-05)  A/B MACs (A) and (B) shall use the appropriate remittance advice notice that appropriately explains the denial of payment.   100.7 - Claim Adjustment Reason Code  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01- 03-05)  A/B MACs (A) and (B) shall use claims adjustment reason code 119 Benefit maximum for this time period has been reached.   110 - Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  Section 1861(s)(2)(AA) and 1861(bbb) of the Social Security Act and implementing regulations at 42 CFR 410.19 authorize coverage under Medicare Part B for a one -time ultrasound screening for abdominal aortic aneurysm (AAA), effective January 1, 2007.   110.1 - Definitions  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  The term ultrasound screening for abdominal aortic aneurysm means the following services furnished to an asymptomatic individual for the early detection of an abdominal aortic aneurysm:   1. a procedure using sound waves (or such other procedures using alternative technologies, of commensurate accuracy and cost, as specified by the Secretary of Health and Human Services, through the national coverage determination process) provided for the ear ly detection of abdominal aortic aneurysms; and   2. includes a physician's interpretation of the results of the procedure.   110.2 - Coverage  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  Payment may be made for a one- time ultrasound screening for AAA for beneficiaries who meet the following criteria:   (i) receives a referral for such an ultrasound screening from the beneficiarys attending physician, physician assistant, nurse practitioner or clinical nurse specialist;   (ii) receives such ultrasound screening from a provider or supplier who is authorized to provide covered ultrasound diagnostic services;   (iii) has not been previously furnished such an ultrasound screening under the Medicare Program; and   (vi) is included in at least one of the following risk categories --   (I) has a family history of abdominal aortic aneurysm;   (II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or   (III) is a beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and Human Services, through the national coverage determination process.   110.3 - Payment  (Rev. 1113, Issued: 11- 17-06, Effective: 01 -01-07, Implementation: 01- 02-07)  If the screening is provided in a physician office, the service is billed to the A/B MAC (B) using the HCPCS code identified in section 110.3.2 below.  Payment is under the Medicare Physicians Fee Schedule (MPFS).  A/B MACs (A) shall pay for the AAA screening only when the services are performed in a hospital, including a critical access hospital (CAH), Indian Health Service (IHS) Facility, Skilled Nursing Facility (SNF), Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC) and submitted on one of the following types of bills (TOBs): 12X, 13X, 22X, 23X, 71X, 73X, 85X.  The following describes the payment methodology for AAA Screening:   Facility  Type of Bill  Payment  Hospitals subject to OPPS  12X, 13X  OPPS  Method I and Method II Critical Access Hospitals (CAHs)  12X and 85X  101% of reasonable cost  IHS providers  13X, revenue code 051X  OMB -approved outpatient per visit all inclusive rate (AIR)  IHS providers  12X, revenue code 024X  All-inclusive inpatient ancillary per diem rate  IHS CAHs  85X, revenue code 051X  101% of the all -inclusive facility specific per visit rate Facility  Type of Bill  Payment  IHS CAHs  12X, revenue code 024X  101% of the all -inclusive facility specific per diem rate SNFs **  22X, 23X  Non-facility rate on the MPFS  RHCs*  71X, revenue code 052X  All-inclusive encounter rate  FQHCs*  73X, revenue code 052X  All-inclusive encounter rate  Maryland Hospitals under jurisdiction of the Health Services Cost Review Commission (HSCRC)  12X, 13X  94% of provider submitted charges or according to the terms of the Maryland Waiver   * If the screening is provided in an RHC or FQHC, the professional portion of the service is billed to the A/B MAC (A) using TOBs 71X and 73X, respectively, and the appropriate site of service revenue code in the 052X revenue code series.   If the screening is provided in an independent RHC or freestanding FQHC, the technical component of the service can be billed by the practitioner to the A/B MAC (B) under the practitioners ID following instructions for submitting practitioner claims to th e Medicare A/B MAC (B).   If the screening is provided in a provider -based RHC/FQHC, the technical component of the service can be billed by the base provider to the A/B MAC (A) under the base providers ID, following instructions for submitting claims to the A/B MAC (A) from the b ase provider.   ** The SNF consolidated billing provision allows separate part B payment for screening services for beneficiaries that are in skilled Part A SNF stays, however, the SNF must submit these services on a 22X bill type.  Screening services provided by other pr ovider types must be reimbursed by the SNF.   110.3.1 - Deductible and Coinsurance  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  The Part B deductible and coinsurance for screening AAA is waived.   110.3.2 - HCPCS Code  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  Effective for services furnished on or after January 1, 2007 through December 31, 2016, the following code and modifiers are used for AAA screening services:   G0389: Ultrasound, B -scan and or real time with image documentation; for abdominal aortic aneurysm (AAA) screening   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.