(Medicare Claims Processing Manual)

 Claim adjustment reason code 119 -  Benefit maximum for this time period has been reached at the line level, and    Remark code M83 - Service is not covered unless the patient is classified as at high risk at the line item level.   HPV Screening: Effective for claims with dates of service on and after July 9, 2015:   A. If denying line -items on claims containing HCPCS G0476, HPV screening, when reported more than once in a 5- year period [at least 4 years and 11 months (59 months total) must elapse from the date of the last screening], use the following messages:   CARC 119: Benefit maximum for this time period or occurrence has been reached.   RARC N386: This decision was based on a National Coverage Determination (NCD).  An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.   Group Code PR (Patient Responsibility) assigning financial responsibility 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).  B. If denying line -items on claims containing HCPCS G0476, HPV screening, when the beneficiary is not between the ages of 30 -65, use the following messages:   CARC 6: The procedure/revenue code is inconsistent with the patient's age.  Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N129: Not eligible due to the patients age.   Group Code PR (Patient Responsibility) assigning financial responsibility 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).  C. If denying line items on claims containing HCPCS G0476, HPV screening, when the claim does not contain the appropriate ICD -10 diagnosis codes listed below:   ICD-10: Z11.51 and Z01.411, or, Z01.419  Use the following messages:   CARC 167  This (these) diagnosis(es) is (are) not covered.  Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N386  This decision was based on a National Coverage Determination (NCD).  An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.   Group Code CO assigning financial liability to the provider   40 - Screening Pelvic Examinations  (Rev. 1541, Issued: 06- 20-08, Effective: 09 -23-08, Implementation: 09- 23-08)  Section 4102 of the BBA of 1997 (P.L. 105- 33) amended 1861(nn)  of the Act (42 USC 1395X(nn)) to include Medicare Part B coverage of screening pelvic examinations (including a clinical breast examination) for all female beneficiaries for services provided January 1, 1998 and later.  Effective July 1, 2001, the Consoli dated Appropriations Act of 2001 (P.L. 106- 554) modifies 1861(nn) to provide Medicare Part B coverage for biennial screening pelvic examinations.  A screening pelvic examination with or without specimen collection for smears and cultures, should include a t least seven of the following eleven elements:    Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge;    Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses;    External genitalia (for example, general appearance, hair distribution, or lesions);    Urethral meatus (for example, size, location, lesions, or prolapse);    Urethra (for example, masses, tenderness, or scarring);    Bladder (for example, fullness, masses, or tenderness);    Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele);    Cervix (for example, general appearance, lesions or discharge)    Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support);    Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity); and    Anus and perineum.   40.1 - Screening Pelvic Examinations From January 1, 1998, Through June 30 2001 (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  B3-4603.2.A, B3- 4603.5, A3- 3628.1.B.1, R1888.A.3 Dated 6- 3-2003   The following requirements must be met.  The exam must be performed by a doctor of medicine or osteopathy (as defined in 1861(r)(1)  of the Act), or by a certified nurse midwife (as defined in 1861(gg)  of the Act), or a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in 1861(aa) of the Act) who is authorized under State law to perform the examination.  This examination does not have to be ordered by a physician or other authorized practitioner.   Payment may be made: Once every three years on an asymptomatic woman only if the individual has not had a screening pelvic examination paid for by Medicare during the preceding 35 months following the month in which the last Medicare -covered screening pelv ic examination was performed.  Providers use ICD -10-CM codes for the low risk factors.  Exceptions are as follows:    Payment may be made for a screening pelvic examination performed more frequently than once every 35 months if the test is performed by a physician or other practitioner and there is evidence that the woman is at high risk (on the basis of her medical history or other findings) of developing cervical cancer, or vaginal cancer.  Providers use ICD -10-CM codes for the high risk factors for cervical and vaginal cancer are:   Cervical Cancer High Risk Factors    Early onset of sexual activity (under 16 years of age)    Multiple sexual partners (five or more in a lifetime)    History of a sexually transmitted disease (including HIV infection)    Fewer than three negative or any Pap smears within the previous seven years   Vaginal Cancer High Risk Factors    DES (diethylstilbestrol) -exposed daughters of women who took DES during pregnancy.   ICD-10-CM code Z92.89, Personal history of other medical treatment is used to indicate that one or more of these factors is present; or    Payment may also be made for a screening pelvic examination performed more frequently than once every 36 months if the examination is performed by a physician or other practitioner, for a woman of childbearing age, who has had such an examination that indicated the presence of cervical or vaginal cancer or other abnormality during any of the preceding three years.  The term women of childbearing age means a woman who is premenopausal, and has been determined by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or other  findings.  Payment is not made for a screening pelvic examination for women at high risk or who qualify for coverage under the childbearing provision more frequently than once every 11 months after the month that the last screening pelvic examination cove red by Medicare was performed.    For claims with dates of service on or after July 1, 2001, if the beneficiary does not qualify for an annual screening pelvic exam as noted above, pay for the screening pelvic exam only after at least 23 months have passed following the month during which the beneficiary received her last covered screening pelvic exam.  All other coverage and payment requirements remain the same.   Calculating the Frequency Limitations   To determine the screening periods, start counts beginning with the month after the month in which a previous test/procedure was performed.   Frequency Limitation Example   A beneficiary identified as being at high risk for developing cervical cancer received a pelvic exam in January 2002.  Start counts beginning with February 2002.  The beneficiary is eligible to receive another screening exam, if high risk, in January 2003 (the month after 11 full months have passed).   40.2 - Screening Pelvic Examinations on and After July 1, 2001  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  When the beneficiary does not qualify for a more frequently performed screening pelvic exam noted in 40.1 of this chapter, items 2, or 3, the screening pelvic exam may be paid only after at least 23 months have passed following the month during which the beneficiary received her last covered screening pelvic exam.  All other coverage, claim preparation, and p ayment requirements remain the same, except ICD -10-CM codes replace ICD -9-CM codes when mandated.   40.3 - Deductible and Coinsurance  (Rev. 1, 10- 01-03)  B3-4603.2.C, A3- 3628.1.B.3  The Part B deductible for screening pelvic examinations is waived effective January 1, 1998.  Coinsurance is applicable.   A. Action When Submitting Claims to CWF and CWF Edit   B3-4603.4, B3- 4603.6, A3- 3628.1.C.1   When an A/B MAC (B) receives a claim for a pelvic examination, performed on or after January 1, 1998, it must enter a deductible indicator of 1 (not subject to deductible) in field 65 of the HUBC record.   When an A/B MAC (A) receives a claim for a screening pelvic examination (including a clinical breast examination), performed on or after January 1, 1998, it reports special override Code 1 in the Special Action Code/Override Code field of the CWF record for the line item, indicating the Part B deductible does not apply.  CWF edits for screening pelvic examinations performed more frequently than allowed according to the presence of high risk factors.   40.4 - Diagnoses Codes                                                                                                            (Rev. 11445, Issued:06- 03-22 Effective:05 -09-22, Implmentation:05- 09-22)  Below are the current diagnoses that should be used when billing for screening pelvic examination services. Effective Oct 1, 2015 the following chart lists for the ICD -10-CM codes that CWF must recognize for low risk or high- risk patients for screening pelvic examination services.    Low Risk Diagnosis Codes    ICD-10-CM codes  Description  Z01.411  Encounter for gynecological examination (general) (routine) with abnormal findings  Z01.419  Encounter for gynecological examination (general) (routine) without abnormal findings  Z12.4  Encounter for screening for malignant neoplasm of cervix  Z12.72  Encounter for screening for malignant neoplasm of vagina  Z12.79  Encounter for screening for malignant neoplasm of other genitourinary organs  Z12.89  Encounter for screening for malignant neoplasm of other sites    High Risk Diagnosis Codes   ICD-10-CM codes   Description  Z77.9  Other contact with and (suspected) exposures hazardous to health  Z77.29  Contact with and (suspected) exposure to other hazardous substances  Z72.51  High risk heterosexual behavior  Z72.52  High risk homosexual behavior  Z72.53  High risk bisexual behavior  Z91.89  Other specified personal risk factors, not elsewhere classified  Z92.850  Personal history of Chimeric Antigen Receptor T -cell therapy  Z92.858  Personal history of other cellular therapy  Z92.86  Personal history of gene therapy  Z92.89  Personal history of other medical treatment   A. Applicable Diagnoses for Billing an A/B MAC (B)