(Medicare Claims Processing Manual)

The professional component is billed to the A/B MACs (B) on Form CMS -1500 (or electronic equivalent).  A/B MACs (A) and (B) were furnished a mammography benefit pricing file to pay claims containing the above codes.  20.8 - Beneficiary and Provider Notices  (Rev. 1, 10- 01-03)  B3-4601.4, A3- 3660.10.I, SNF -537.2.G   20.8.1 - MSN Messages (Rev. 3961, Issued: 02- 02- 18, Effective: 01 -01- 18, Implementation: 07- 02-18)  B3-4601.4, A3- 3660.10.I  The following messages are used on the MSN. If the claim is denied because the beneficiary is under 35 years of age, use the following MSN:  MSN 18.3:   Screening mammography is not covered for women under 35 years of age.  The Spanish version of this MSN message should read:  Las pruebas de mamografa para mujeres menores de 35 aos no estn cubiertas.  If the claim is denied for a woman 35- 39 because she has previously received this examination, use the following MSN:  MSN 18.6:  A screening mammography is covered only once for women age 35- 39.  The Spanish version of this MSN message should read:  Una mamografa de cernimiento es cubierta una vez solamente para mujeres entre las edades de 35 -39. If the claim is denied because the period of time between screenings for the woman based on age has not passed, use the following MSN:  MSN 18.4:  This service is being denied because it has not been 12 months since your last examination of this kind.  (NOTE: Insert appropriate number of months.)  The Spanish version of this MSN message should read:  Este servicio se deneg debido a que no han transcurrido 12 meses desde su ltimo examen de este tipo.  If the claim is denied because the provider is not certified to perform a mammography, use the following MSN:  MSN 16.2:  This service cannot be paid when provided in this location/facility. The Spanish version of this MSN message should read:  Este servicio no se puede pagar cuando es suministrado en este sitio/facilidad. In addition to the above denial messages, the A/B MAC (A) or (B) may add the following:  MSN 18.12:   Screening mammograms are covered annually for women 40 years of age and older. The Spanish version of this MSN message should read:  El examen de mamografa de cernimiento se cubre una vez al ao para mujeres de 40 aos de edad o ms.  For A/B MACs (B) only:  For claims submitted with invalid or missing certification number, use the following MSN:  MSN 9.2:  This item or service was denied because information required to make payment was missing.  The Spanish version of this MSN message should read:  Este artculo o servicio fue denegado porque la informacin requerida para hacer el pago fue omitida.   20.8.2 - Remittance Advice Messages  (Rev. 3961, Issued: 02- 02- 18, Effective: 01 -01- 18, Implementation: 07- 02-18)  If the claim is denied because the beneficiary is under 35 years of age, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with C AQH CORE Business Scenario Three.   CARC: 6  RARC: M37    Group Code: CO   If the claim is denied for a woman 35- 39 because she has previously received this examination, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   CARC: 119  RARC: M89   Group Code: CO   If the claim is denied for a woman age 40 and above because she has previously received this examination within the past 12 months, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under t his policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   CARC: 119  RARC: M90  Group Code: CO    If the claim is denied because the provider that performed the screening is not certified to perform the type of mammography billed (film or digital) the contractor shall use the following remittance advice messages and associated codes when rejecting/deny ing claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   CARC: B7  RARC: N570    Group Code: CO  For claims that were submitted without the facilitys FDA -assigned certification number, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   CARC: 16  RARC: MA128  Group Code: CO  For claims that were submitted with an invalid facility certification number, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant w ith CAQH CORE Business Scenario Two.   CARC: 16  RARC: MA128  Group Code: CO    30 - Screening Pap Smears  (Rev. 1, 10- 01-03)  A3-3628.1, B3- 4603.1, B3- 4603.1A, SNF -541.2  Effective January 1, 1998, 1861(nn)  of the Act (42 USC 1395x(nn)) provides Medicare Part B coverage for a screening Pap smear for women under certain conditions.  See the Medicare Benefit Policy Manual, Chapter 15, for coverage of screening PAP smears.  To be covered screening Pap smears must be ordered and collected by a doctor of medicine or osteopathy (as defined in 1861(r)(l)  of the Act), or other authorized practitioner (e.g., a certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist, who is authorized under State law to perform the examination) under one  of the conditions identified in 30.1, below.   30.1 - Pap Smears From January 1, 1998, Through June 30 2001  (Rev. 1, 10- 01-03)  B3-4603.1A.1, B3- 4603.1A.2, B3- 4603.1A.3, A3 -3628.1A   The following requirements must be met.  1. The beneficiary has not had a screening Pap smear test during the preceding three years (i.e., 35 months have passed following the month that the woman had the last covered Pap smear.  Use one of the following ICD -9-CM codes V76.2, V76.47, or V76.49; or   2. There is evidence (on the basis of her medical history or other findings) that she is of childbearing age and has had an examination that indicated the presence of cervical or vaginal cancer or other abnormalities during any of the preceding 3 years; and at least 11 months have passed following the month that the last covered Pap smear was performed; or    3. She is at high risk of developing cervical or vaginal cancer (use ICD -9-CM code V15.89, other specified personal history presenting hazards to health) and  at least 11 months have passed following the month that the last covered screening Pap smear was performed.  The high risk factors for cervical and vaginal cancer are:   a. Cervical Cancer High Risk Factors:    Early onset of sexual activity (under 16 years of age)    Multiple sexual partners (5 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 7 years   b. Vaginal Cancer High Risk Factors:    DES (diethylstilbestrol) -exposed daughters of women who took DES during pregnancy.   NOTE:  The term woman 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.  COUNTING: To determine the 11- , 23-, and 35 -month periods, start counts beginning with the month after the month in which a previous test/procedure was performed.   COUNTING EXAMPLE: A beneficiary identified as being at high risk for developing cervical cancer received a screening Pap smear in January 2000.  Start counts beginning with February 2000.  The beneficiary is eligible to receive another screening Pap smear in January 2001 (the month after 11 full months have passed) .  30.2 - Pap Smears On and After July 1, 2001  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  If the beneficiary does not qualify for more frequent screening based on paragraphs (2) and (3) above, for services performed on or after July 1, 2001, payment may be made for a screening PAP smear after 23 months have passed after the end of the month of the last covered smear.  All other coverage and payment requirements remain the same, except ICD -10-CM codes replace ICD -9-CM codes when mandated.  30.2.1  Screening for Cervical Cancer with Human Papillomavirus (HPV) Testing  (Rev. 3460, Issued: 02- 05-16, Effective: 07 -09-16, Implementation: 03- 07-16 - for non -shared MAC edits; 07 -05-16 - CWF analysis and design; 10- 03-16 - CWF Coding, Testing and Implementation, MCS, and FISS Implementation; 01 -03-17 - Requirement BR9434.04.8.2)   See the Medicare National Coverage Determinations (NCD) Manual, Pub 100- 03, Section 210.2.1 for complete coverage requirements for s creening for cervical cancer with Human Papillomavirus testing (HPV).    The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to add HPV testing once every five years as an additional preventive service benefit under the Medicare program for asymptomatic beneficiaries aged 30 to 65 y ears in conjunction with the Pap smear test. CMS will cover screening for cervical cancer with the appropriate U.S. Food and Drug Administration (FDA) -approved/cleared laboratory tests, used consistent with FDA -approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations.   Effective for claims with dates of service on or after July 9, 2015, payment may be made for HCPCS G0476 (cervical cancer screening, all -inclusive HPV co -test with cytology (Pap smear) to detect HPV DNA or RNA sequences).    For claims with date of service from July 9, 2015 through December 31, 2016, HCPCS G0476 will be contractor priced. Beginning with date of service January 1, 2017 and after, HCPCS G0476 will be priced and paid according to the CLFS.  G0476 will be included in the January 2017 CLFS, January 1, 2016 IOCE, the January 2016 OPPS and January 1, 2016 MPFSD.  HCPCS G0476 will be effective retroactive to July 9, 2015 in the IOCE & OPPS.   Effective for claims with dates of service on or after July 9, 2015, payment may be made for HCPCS G0476 (cervical cancer screening, all -inclusive HPV co -test with cytology (Pap smear) to detect HPV DNA or RNA sequences) only when submitted with a Place of  Service Code equal to 81, Independent Lab or 11, Office.   A.  Screening Pap Smears: A/B MAC (B)  Action for Submitting Claims to the Common Working File (CWF) and CWF Edit   When a A/B MAC (B) receives a claim for a screening Pap smear, performed on or after January 1, 1998, it must enter a deductible indicator of 1 (not subject to deductible) in field 67 of the HUBC record.   CWF will edit for screening pelvic examinations performed more frequently than allowed according to the presence of high risk factors.   30.3 - Deductible and Coinsurance  (Rev. 1, 10- 01-03)  B3-4603.4, A3- 3628.1.A.3