(Medicare Claims Processing Manual)

MSN 21.18:  This item or service is not covered when performed or ordered by this provider.   Spanish version:  Este servicio no esta cubierto cuando es ordenado o rendido por este proveedor.   Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  160.3 - Correct Types of Bill (TOB) for IBT for CVD on Institutional Claims  (Rev. 2432, Issued: 03- 23-12, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04-02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   Effective for claims with dates of service on and after November 8, 2011, the following types of bill (TOB) may be used for IBT for CVD: 13X, 71X, 77X, or 85X.  All other TOB codes shall be denied.   The following messages shall be used when A/B MACs (A) deny claims for G0446 when submitted on a TOB other than those listed above:   CARC 170:  Payment is denied when performed/billed by this type of provider.  Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N428:  Not covered when performed in this place of service.   MSN 21.25:  This service was denied because Medicare only covers this service in certain settings.   Spanish Version:  El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  160.4 - Frequency Edits for IBT for CVD Claims  (Rev. 2432, Issued: 03- 23-12, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04-02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   A/B MACs (A) and (B) shall allow claims for G0446 no more than once in a 12- month period.   NOTE:  11 full months must elapse following the month in which the last G0446 IBT for CVD took place.   MACs shall deny claims IBT for CVD claims that exceed one (1) visit every 12 months.  A/B MACs (A) and (B) shall allow one professional service and one facility fee claim for each visit.   The following messages shall be used when A/B MACs (A) and (B) deny IBT for CVD claims that exceed the frequency limit:  CARC 119:  Benefit maximum for this time period or occurrence has been reached.   RARC N362:  The number of days or units of service exceeds our acceptable maximum.   MSN 20.5:  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version:  Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  160.5 - Common Working File (CWF) Edits for IBT for CVD Claims  (Rev. 2432, Issued: 03- 23-12, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04-02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   When applying frequency, CWF shall count 11 full months following the month of the last IBT for CVD, G0446 before allowing subsequent payment of another G0446 screening.   When applying frequency limitations to G0446, CWF shall allow both a claim for the professional service and a claim for the facility fee.  CWF shall identify the following institutional claims as facility fee claims for screening services:  TOB 13X, TOB85X  when the revenue code is not 096X, 097X, or 098X.  CWF shall identify all other claims as professional service claims for screening services.   NOTE:  This does not apply to RHCs and FQHCs.  170 - Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs  (Rev. 2476, Issued: 05- 23-12, Effective: 11 -08-11, Implementation: 02- 27-12)  170.1 - Healthcare Common Procedure Coding System (HCPCS) Codes for Screening for STIs and HIBC to Prevent STIs  (Rev. 11759, Issued:12- 21-2022, Effective:01 -23-2023, Implementation:01- 23-2023)   Effective for claims with dates of service on and after November 8, 2011, the claims processing instructions for payment of screening tests for STI will apply to the following HCPCS/CPT codes:    Chlamydia:    86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810, 87800,    0353U - effective 10/01/22 (used for combined chlamydia and gonorrhea testing)    Gonorrhea:   87590, 87591, 87850, 87800,  0353U -  effective 10/01/22 (used for combined chlamydia and gonorrhea testing)    Syphilis: 86592, 86593, 86780   Hepatitis B: (hepatitis B surface antigen): 87340, 87341  Effective for claims with dates of service on and after November 8, 2011, implemented with the January 2, 2012, IOCE, the following HCPCS code is to be billed for HIBC to prevent STIs :   G0445 -  high- intensity behavioral counseling to prevent sexually transmitted infections, face -to-face, individual, includes: education, skills training, and guidance on how to change sexual behavior, performed semi -annually, 30 minutes.   170.2 - Diagnosis Code Reporting  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  A claim that is submitted for screening chlamydia, gonorrhea, syphilis, and/or hepatitis B shall be submitted with one or more of the following diagnosis codes in the header and pointed to the line item:   a. For claims for screening for chlamydia, gonorrhea, and syphilis in women at increased risk who are not pregnant use the following ICD -10-CM diagnosis codes:     Z11.3 -  Encounter for screening for infections with a predominantly sexual mode of transmission;   And any of   o Z72.89 -  Other problems related to lifestyle, or  o Z72.51 -  High risk heterosexual behavior, or  o Z72.52 -  High risk homosexual behavior, or  o Z72.53 - High risk bisexual behavior (These diagnosis codes are used to indicate high/increased risk for STIs).   b. For claims for screening for syphilis in men at increased risk use the following ICD -10-CM diagnosis codes:    Z11.3 -  Encounter for screening for infections with a predominantly sexual mode of transmission; and   And any of   o Z72.89 -  Other problems related to lifestyle, or  o Z72.51 -  High risk heterosexual behavior, or  o Z72.52 -  High risk homosexual behavior, or  o Z72.53 - High risk bisexual behavior (These diagnosis codes are used to indicate high/increased risk for STIs).    c. For claims for screening for chlamydia and gonorrhea in pregnant women at increased risk for STIs use the following ICD -10-CM diagnosis codes, if applicable:    Z11.3 -  Encounter for screening for infections with a predominantly sexual mode of transmission; and  one of:  o Z72.89 -  Other problems related to lifestyle, or  o Z72.51 -  High risk heterosexual behavior, or  o Z72.52 -  High risk homosexual behavior, or  o Z72.53 - High risk bisexual behavior (These diagnosis codes are used to indicate high/increased risk for STIs).   and also one of the following.  Code  Description  Z34.00  Encounter for supervision of normal first pregnancy, unspecified trimester  Z34.01  Encounter for supervision of normal first pregnancy, first trimester  Z34.02  Encounter for supervision of normal first pregnancy, second trimester  Z34.03  Encounter for supervision of normal first pregnancy, third trimester  Z34.80  Encounter for supervision of other normal pregnancy, unspecified trimester  Z34.81  Encounter for supervision of other normal pregnancy, first trimester  Z34.82  Encounter for supervision of other normal pregnancy, second trimester  Z34.83  Encounter for supervision of other normal pregnancy, third trimester  Code  Description  Z34.90  Encounter for supervision of normal pregnancy, unspecified, unspecified trimester  Z34.91  Encounter for supervision of normal pregnancy, unspecified, first trimester  Z34.92  Encounter for supervision of normal pregnancy, unspecified, second trimester  Z34.93  Encounter for supervision of normal pregnancy, unspecified, third trimester  O09.90  Supervision of high risk pregnancy, unspecified, unspecified trimester  O09.91  Supervision of high risk pregnancy, unspecified, first trimester  O09.92  Supervision of high risk pregnancy, unspecified, second trimester  O09.93  Supervision of high risk pregnancy, unspecified, third trimester     d. For claims for screening for syphilis in pregnant women use the following ICD -10-CM diagnosis codes:     Z11.3 -  Encounter for screening for infections with a predominantly sexual mode of transmission;  and one of   Code  Description  Z34.00  Encounter for supervision of normal first pregnancy, unspecified trimester  Z34.01  Encounter for supervision of normal first pregnancy, first trimester  Z34.02  Encounter for supervision of normal first pregnancy, second trimester  Z34.03  Encounter for supervision of normal first pregnancy, third trimester  Z34.80  Encounter for supervision of other normal pregnancy, unspecified trimester  Z34.81  Encounter for supervision of other normal pregnancy, first trimester  Z34.82  Encounter for supervision of other normal pregnancy, second trimester  Z34.83  Encounter for supervision of other normal pregnancy, third trimester  Z34.90  Encounter for supervision of normal pregnancy, unspecified, unspecified trimester  Z34.91  Encounter for supervision of normal pregnancy, unspecified, first trimester  Z34.92  Encounter for supervision of normal pregnancy, unspecified, second trimester  Z34.93  Encounter for supervision of normal pregnancy, unspecified, third trimester  O09.90  Supervision of high risk pregnancy, unspecified, unspecified trimester  O09.91  Supervision of high risk pregnancy, unspecified, first trimester  Code  Description  O09.92  Supervision of high risk pregnancy, unspecified, second trimester  O09.93  Supervision of high risk pregnancy, unspecified, third trimester   e. For claims for screening for syphilis in pregnant women at increased risk for STIs use the following ICD -10-CM diagnosis codes:    Z11.3 -  Encounter for screening for infections with a predominantly sexual mode of transmission;  and any of:   o Z72.89 -  Other problems related to lifestyle, or  o Z72.51 -  High risk heterosexual behavior, or  o Z72.52 -  High risk homosexual behavior, or  o Z72.53 - High risk bisexual behavior (These diagnosis codes are used to indicate high/increased risk for STIs).    and also one of the following: