(Medicare Benefit Policy Manual)

See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services, for coverage requirements for the following:    40 for screening pelvic examinations,   50 for prostate cancer screening test and procedures,    60 for colorectal cancer screening, and,    70.4 for glaucoma screening.  280.1  Glaucoma Screening  (Rev. 194, Issued: 09- 03-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)  A.  Conditions of Coverage   The regulations implementing the Benefits Improvements and Protection Act of 2000, 102, provide for annual coverage for glaucoma screening for beneficiaries in the following high risk categories:    Individuals with diabetes mellitus;   Individuals with a family history of glaucoma; or   African -Americans age 50 and over.   In addition, beginning with dates of service on or after January 1, 2006, 42 CFR 410.23(a)(2), revised, the definition of an eligible beneficiary in a high- risk category is expanded to include:    Hispanic -Americans age 65 and over.   Medicare will pay for glaucoma screening examinations where they are furnished by or under the direct supervision in the office setting of an ophthalmologist or optometrist, who is legally authorized to perform the services under State law.   Screening for glaucoma is defined to include:    A dilated eye examination with an intraocular pressure measurement; and   A direct ophthalmoscopy examination, or a slit -lamp biomicroscopic examination.  Payment may be made for a glaucoma screening examination that is performed on an eligible beneficiary after at least 11 months have passed following the month in which the last covered glaucoma screening examination was performed.   The following HCPCS codes apply for glaucoma screening:   G0117 -  Glaucoma screening for high- risk patients furnished by an optometrist or ophthalmologist; and   G0118 -  Glaucoma screening for high- risk patients furnished under the direct supervision of an optometrist or ophthalmologist.   The type of service for the above G codes is: TOS Q.  For providers who bill A/B MACs, applicable types of bill for screening glaucoma services are 13X, 22X, 23X, 71X, 73X, 75X, and 85X.  The following revenue codes should be reported when billing for screening glaucoma services:    Comprehensive outpatient rehabilitation facilities (CORFs), critical access hospitals (CAHs), skilled nursing facilities (SNFs), independent and provider -based RHCs and free standing and provider -based FQHCs bill for this service under revenue code 770.  C AHs electing the optional method of payment for outpatient services report this service under revenue codes 96X, 97X, or 98X.   Hospital outpatient departments bill for this service under any valid/appropriate revenue code.  They are not required to report revenue code 770.   o Calculating the Frequency    Once a beneficiary has received a covered glaucoma screening procedure, the beneficiary may receive another procedure after 11 full months have passed.  To determine the 11 -month period, start the count beginning with the month after the month in which the  previous covered screening procedure was performed.   o Diagnosis Coding Requirements    Providers bill glaucoma screening using diagnosis codes for screening services.  Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable.  o Payment Methodology   A/B MACs (B)   o Contractors pay for glaucoma screening based on the Medicare physician fee schedule.  Deductible and coinsurance apply.  Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge (refer to the Medicare Claims Processing Manual, Chapter 12, Physician/Non- physician Practitioners, for more information about the Medicare limiting charge).    A/B MACs (A)   o Payment is made for the facility expense as follows:    Independent and provider -based RHC/free standing and provider -based FQHC - payment is made under the all inclusive rate for the screening glaucoma service based on the visit furnished to the RHC/FQHC patient;    CAH -  payment is made on a reasonable cost basis unless the CAH has elected the optional method of payment for outpatient services in which case, procedures outlined in the Medicare Claims Processing Manual, Chapter 3, 30.1.1, should be followed;    CORF -  payment is made under the Medicare physician fee schedule;    Hospital outpatient department -  payment is made under outpatient prospective payment system (OPPS);    Hospital inpatient Part B - payment is made under OPPS;   SNF outpatient - payment is made under the Medicare physician fee schedule (MPFS); and    SNF inpatient Part B - payment is made under MPFS.  Deductible and coinsurance apply.  E.  Special Billing Instructions for RHCs and FQHCs   Screening glaucoma services are considered RHC/FQHC services.  RHCs and FQHCs bill the contractor under bill type 71X or 73X along with revenue code 770 and HCPCS codes G0117 or G0118 and RHC/FQHC revenue code 520 or 521 to report the related visit.  Reporting of revenue code 770 and HCPCS codes G0117 and G0118 in addition to revenue code 520 or 521 is required for this service in order for CWF to perform frequency editing.  Payment should not be made for a screening glaucoma service unless the claim also contains a visit code for the service.  Therefore, the contractor installs an edit in its system to assure payment is not made for revenue code 770 unless the claim also cont ains a visit revenue code (520 or 521).  280.2 - Colorectal Cancer Screening  (Rev. 1, 10-01-03) B3-4180  280.2.1 - Covered Services and HCPCS Codes  See Business Requirements at http://cms.hhs.gov/manuals/pm_trans/R3BP.pdf  (Rev. 3, 12-19-03) B3-4180.1  Medicare covers colorectal cancer screening test/procedures for the early detection of colorectal cancer for the HCPCS codes indicated.   A. Effective for Services Furnished On or After January 1, 1998:   G0107 - Colorectal cancer screening; fecal -Occult blood test, 1-3 simultaneous determinations;  G0104 - Colorectal cancer screening; flexible sigmoidoscopy;  G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;  G0106 - Colorectal cancer screening  barium enema ; alternative to GO104, screening sigmoidoscopy;  G0120 -  Colorectal cancer screening  barium enema ; alternative to GO105, screening sigmoidoscopy.  B. Effective for Services Furnished On or After July 1, 2001:   G0121 -  Colorectal Cancer Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk   C. Effective for Services Furnished On or After January 1, 2004:   G0328 - Colorectal cancer screening; fecal -occult blood test, immunoassay, 1- 3 simultaneous determinations.   280.2.2 - Coverage Criteria  (Rev. 12299; Issued:10- 12-23; Effective:01 -01-23; Implementation:11 -13-23)  The following are the coverage criteria for these screenings:   A. Screening  Fecal -Occult  Blood  Tests  (FOBT)  (Codes  82270 &  G0328)   Effective for services furnished on or after January 1, 2004, one screening FOBT (code 82270 or G0328)  is covered  for beneficiaries  who have  attained  age 50, at  a frequency  of once every  12 months (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was done). Screening FOBT means: (1) a guaiac- based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools or , (2) an immunoassay (or immunochemical)  test for antibody activity  in which  the beneficiary  completes  the test by taking the appropriate number of samples according to the specific manufacturers instructions.  This expanded coverage is in accordance with revised regulations at 42 CFR 410.37(a)(2) that includes  other tests determined by the Secretary through a national coverage determination.  This screening requires a written order from the beneficiarys attending physician or for claims with dates of service on or after January 27, 2014, from the beneficiarys attending physician assistant, nurse practitioner, or clinical nurse specialist.  (The term attending physician is defined to mean a doct or of medicine  or osteopathy (as defined in 1861(r)(1) of  the Act)  who is fully knowledgeable about the beneficiarys medical condition, and who would be responsible for using the results of any examination performed in the overall management of the beneficiarys specific medical problem.)  NOTE:  For claims  with dates  of service prior to January  1, 2007, physicians, suppliers, and providers report HCPCS code G0107. Effective January 1, 2007, code G0107, is discontinued and replaced with CPT code 82270. For complete claims processing information refer to Pub. 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.  Effective January 1, 2023, the minimum age for FOBT screening tests is reduced to 45 years and older. For complete claims processing information, refer to Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.  B. Screening  Flexible  Sigmoidoscopies  (code G0104)   For claims with dates of service on or after January 1, 2002, A/B MACs (B) pay for screening  flexible  sigmoidoscopies  (Code  G0104)  for beneficiaries  who have attained  age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in  1861(aa)(5)  of the Act and at 42 CFR  410.74, 410.75, and 410.76)  at the frequencies noted below. For claims with dates of service prior to January  1, 2002, pay for these services under the conditions noted only when they are performed by a doctor of medicine or osteopathy.   For services  furnished from  January 1, 1998,  through  June  30, 2001, inclusive   Once every  48 months  (i.e., at least 47 months  have passed  following the month in which the last covered screening flexible sigmoidoscopy was done).   For services  furnished on or after  July 1, 2001   Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to 280.2.3) and the beneficiary  has had a screening  colonoscopy (code G0121)  within  the preceding  10 years. If such a  beneficiary  has had  a screening  colonoscopy  within  the preceding  10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (code G0121).   NOTE:  If during the course of a screening  flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure  classified  as a flexible  sigmoidoscopy with biopsy or removal  should be billed and paid rather than code G0104.   Effective January 1, 2023, the minimum age for Screening Flexible Sigmoidoscopies is reduced to 45 years and older. For complete claims processing information, refer to Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.   C. Screening  Colonoscopies  for Beneficiaries  at High  Risk  of Developing  Colorectal Cancer (Code G0105)   The A/B MAC  (B) must  pay for screening  colonoscopies  (code  G0105)  when  performed by a doctor of medicine  or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed  following the month in which  the last covered  G0105 screening  colonoscopy was performed).  Refer to 280.2.3 for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.