(Medicare Claims Processing Manual)

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:   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  O09.92  Supervision of high risk pregnancy, unspecified, second trimester  O09.93  Supervision of high risk pregnancy, unspecified, third trimester   f. For claims for screening for hepatitis B in pregnant women use the following ICD -10-CM diagnosis codes:     Z11.59 -  Encounter for screening for other viral diseases, and  any of   Z34.00 -  Encounter for supervision of normal first pregnancy, unspecified trimester, or   Z34.80 -  Encounter for supervision of other normal pregnancy, unspecified trimester, or   Z34.90 -  Encounter for supervision of normal pregnancy, unspecified, unspecified trimester, or   O09.90 -  Supervision of high risk pregnancy, unspecified, unspecified trimester.   g. For claims for screening for hepatitis B in pregnant women at increased risk for STIs use the following ICD-10 -CM diagnosis codes:     Z11.59 -  Encounter for screening for other viral diseases, and   Z72.89 -  Other problems related to lifestyle, and    any of  o Z72.51 -  High risk heterosexual behavior, or  o Z72.52 -  High risk homosexual behavior, or  o Z72.53 -  High risk bisexual behavior;   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  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   170.3 - Billing Requirements (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Effective for dates of service November 8, 2011, and later, A/B MACs (A) and (B)  shall recognize HCPCS code G0445 for HIBC.  Medicare shall cover up to two occurrences of G0445 when billed for HIBC to prevent STIs.  A claim that is submitted with HCPCS code G0445 for HIBC shall be submitted with ICD -10-CM diagnosis code Z72.89.  A/B MACs (A) and (B) shall pay for screening for chlamydia, gonorrhea, and syphilis (as indicated by the presence of  ICD -10 is applicable, ICD -10-CM diagnosis code Z11.3;  and/or hepatitis B (as indicated by the presence of ICD -10-CM diagnosis code Z11.59 as follows:    One annual occurrence of screening for chlamydia, gonorrhea, and syphilis (i.e., 1 per 12- month period) in women at increased risk who are not  pregnant ,   One annual occurrence of screening for syphilis (i.e., 1 per 12- month period) in men at increased risk,   Up to t wo occurrences per pregnancy of screening for chlamydia and gonorrhea in pregnant women who are at increased risk for STIs and continued increased risk for the second screening,    One occurrence per pregnancy of screening for syphilis in pregnant women,   Up to an additional two occurrences per pregnancy of screening for syphilis in pregnant women if the beneficiary is at continued increased risk for STIs,    One occurrence per pregnancy of screening for hepatitis B in pregnant women, and,    One additional occurrence per pregnancy of screening for hepatitis B in pregnant women who are at continued increased risk for STIs.   170.4 - Types of Bill (TOBs) and Revenue Codes  (Rev. 2476, Issued: 05- 23-12, Effective: 11 -08-11, Implementation: 02- 27-12)  The applicable types of bill (TOBs) for HIBC screening, HCPCS code G0445, are: 13X, 71X, 77X, and 85X.   On institutional claims, TOBs 71X and 77X, use revenue code 052X to ensure coinsurance and deductible are not applied.  Critical access hospitals (CAHs) electing the optional method of payment for outpatient services report this service under revenue codes 096X, 097X, or 098X.  170.4.1 - Payment Method  (Rev. 2476, Issued: 05- 23-12, Effective: 11 -08-11, Implementation: 02- 27-12)  Payment for HIBC is based on the all -inclusive payment rate for rural health clinics (TOBs 71X) and federally qualified health centers (TOB 77X). Hospital outpatient departments (TOB 13X) are paid based on the outpatient prospective payment system and CAHs  (TOB 85X) are paid based on reasonable cost. CAHs electing the optional method of payment for outpatient services are paid based on 115% of the lesser of the Medicare Physician Fee Schedule (MPFS) amount or submitted charge.   Effective for dates of service on and after November 8, 2011, deductible and coinsurance do not apply to claim lines with G0445.   HCPCS code G0445 may be paid on the same date of service as an annual wellness visit, evaluation and management (E&M) code, or during the global billing period for obstetrical care, but only one G0445 may be paid on any one date of service.  If billed on t he same date of service with an E&M code, the E&M code should have a distinct diagnosis code other than the diagnosis code used to indicate high/increased risk for STIs for the G0445 service.  An E&M code should not be billed when the sole reason for the visit is HIBC to prevent STIs.   For Medicare Part B physician and non- practitioner claims, payment for HIBC to prevent STIs is based on the MPFS amount for G0445.  170.5 - Specialty Codes and Place of Service (POS)  (Rev. 2476, Issued: 05- 23-12, Effective: 11 -08-11, Implementation: 02- 27-12)  Medicare provides coverage for  screening for chlamydia, gonorrhea, syphilis, and/or hepatitis B and HIBC to prevent STIs only when ordered by a primary care practitioner (physician or non- physician) with any of the following specialty codes:    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   Medicare provides coverage for HIBC to prevent STIs only when provided by a primary care practitioner (physician or non- physician) with any of the specialty codes identified above.  Medicare provides coverage for  HIBC to prevent STIs only when the POS billed is 11, 22, 49, or 71.  180 - Alcohol Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   The United States Preventive Services Task Force (USPSTF) defines alcohol misuse as risky, hazardous, or harmful drinking which places an individual at risk for future problems with alcohol consumption.  In the general adult population, alcohol consumption becomes risky or hazardous when consuming:    Greater than 7 drinks per week or greater than 3drinks per occasion for women and persons greater than 65 years old.    Greater than 14 drinks per week or greater than 4 drinks per occasion for men 65 years old and younger.   180.1 - Policy  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   Claims with dates of service on and after October 14, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover annual alcohol misuse screening (HCPCS code G0442) consisting of 1 screening session, and for those that screen positive, up to 4 brie f, face -to-face behavioral counseling sessions (HCPCS code G0443) per 12 -month period  for Medicare beneficiaries, including pregnant women.  Medicare beneficiaries that may be identified as having a need for behavioral counseling sessions include those:    Who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and,    Who are competent and alert at the time that counseling is provided; and,   Whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.   Once a Medicare beneficiary has agreed to behavioral counseling sessions, the counseling sessions are to be completed based on the 5As approach adopted by the United States Preventive Services Task Force (USPSTF.)  The steps to the 5As approach are listed below.   1. Assess:  Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.  2. Advise :  Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.   3. Agree:  Collaboratively select appropriate treatment goals and methods based on the patients interest in and willingness to change the behavior.   4. Assist :  Using behavior change techniques (self -help and/or counseling), aid the patient in achieving agreed -upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.   5. Arrange:  Schedule follow -up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.