(Medicare Claims Processing Manual)

Hospitals subject to OPPS (TOBs 12X and 13X) must use modifier - 25 when billing the IPPE G0344 along with the technical component of the EKG, G0367, on the same claim.  The same is true when billing IPPE code G0402 along with the technical component of the screening EKG, code G0404.  This is due to an OPPS Outpatient Code Editor (OCE) which contains an edit that requires a modifier - 25 on any evaluation and management (E/M) HCPCS code if there is also a status S or T HCPCS procedure code on the claim.   80.4 - Coinsurance and Deductible  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.   The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009.  Coinsurance continues to apply for the IPPE provided on or after January 1, 2009.   As a result of the Affordable Care Act, effective for the IPPE provided on or after January 1, 2011, the Medicare deductible and coinsurance (for HCPCS code G0402 only) are waived.  80.5 - Medicare Summary Notices (MSNs)  (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)  When denying additional claims for G0344, G0366, G0367 and G0368, A/B MACs (A) and (B) shall use MSN 18.22 -  This service was denied because Medicare only covers the one- time initial preventive physical exam with an electrocardiogram within the first 6 mon ths that you have Part B coverage, and only if that coverage begins on or after January 1, 2005.   The Spanish version is :  18.22 -  Este servicio fue denegado porque Medicare solamente cubre un examen fisico preventivo con un electrocardiograma dentro de los primeros 6 meses que usted tenga cobertura de la Parte B, y slo si  esta cobertura comienza en o despus del 1 de enero de 2005.  When denying additional claims for G0402 (or claims with dates of service beyond the 12 month period) A/B MACs (A) and (B) shall use MSN 20.91 -  This service was denied.  Medicare covers a one- time initial preventive physical exam (Welcome to Medicare physical exam) if you get it within the first 12 months of the effective date of your Medicare Part B coverage.   The Spanish version is:  Este servicio fue negado.  Medicare cubre un examen fsico de Bienvenido a Medicare ofrecido una sola vez si se obtiene dentro de los primeros 12 meses de la fecha efectiva de su inscripcin a la Parte B de Medicare.   When denying additional claims for screening EKG codes G0403, G0404 and G0405, A/B MACs (A) and (B) shall use MSN 20.12 -  This service was denied because Medicare only covers this service once a lifetime.   The Spanish version is:  Este servicio fue negado porque Medicare slo cubre este servicio una vez en la vida.   80.6 - Remittance Advice Remark Codes (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)  A/B MACs (A) and (B) shall use the appropriate claim Remittance Advice Remark code, such as N117 (This service is paid only once in a patients lifetime) when denying additional claims for an IPPE and/or a screening EKG.   80.7 - Claims Adjustment Reason Codes  (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)  A/B MACs (A) and (B) shall use the appropriate Claim Adjustment Reason code, such as 149 (Lifetime benefit maximum has been reached for this service/benefit category) when denying additional claims for an IPPE and/or a screening EKG.   80.8 - Advanced Beneficiary Notice (ABN) as Applied to the IPPE  (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)  If a second IPPE is billed for the same beneficiary, it would be denied based on Section 1861(s)(2) of the Act, since the IPPE is a one- time benefit, and an ABN would not be required in order to hold the beneficiary liable for the cost of the second IPPE.  However, an ABN should be issued for all IPPEs conducted after the beneficiarys statutory 6- month period has lapsed since based on Section 1862(a)(1)(K), Medicare is statutorily prohibited from paying for an IPPE outside the initial 6- month period under the MMA of 2003.  Effective for  dates of service on or after January 1, 2009, an ABN should be issued for all IPPEs conducted after the beneficiarys statutory 12 -month period has lapsed since based on Section 1862(a)(1)(K), Medicare is statutorily prohibited from paying for an IPPE out side the initial 12 -month period under the MIPPA of 2008.  90 - Diabetes Screening  (Rev. 457, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05)  90.1 - HCPCS Coding for Diabetes Screening  (Rev. 457, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05)  The following HCPCS codes are to be billed for diabetes screening:   82947 -  Glucose, quantitative, blood (except reagent strip)  82950 -  post -glucose dose (includes glucose)  82951 -  tolerance test (GTT), three specimens (includes glucose)   90.2 - A/B MAC (B) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service January 1, 2005 and later, A/B MAC (B) shall recognize the above HCPCS codes for diabetes screening.   A/B MACs (B) shall pay for diabetes screening once every 12 months for a beneficiary that is not pre -diabetic.  A/B MACs (B) shall pay for diabetes screening at a frequency of once every 6 months for a beneficiary that meets the definition of pre -diabetes.   A claim that is submitted for diabetes screening by a physician or supplier for a beneficiary that does not meet the definition of pre -diabetes shall be submitted in the following manner:   The line item shall contain 82947, 82950 or 82951 with a  diagnosis code of V77.1 (if ICD -9-CM is applicable) or (if ICD -10-CM is applicable) diagnosis code Z13.1, encounter for screening for diabetes mellitis reported in the header.   90.2.1 - Modifier Requirements for Pre -diabetes  (Rev. 3329, Issued: 08 -14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A claim that is submitted for diabetes screening and the beneficiary meets the definition of pre -diabetes shall be submitted in the following manner:   The line item shall contain 82497, 82950 or 82951 with an ICD -9-CM diagnosis code of V77.1 reported (if ICD-9-CM is applicable) or, if ICD -10-CM is applicable, a diagnosis code of Z13.1in the header.  In addition, modifier TS (follow -up service) shall be reported on the line item.   90.3 - A/B MAC (A) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service January 1, 2005 and later, A/B MACs (A) shall recognize the above HCPCS codes for diabetes screening.   A/B MACs (A)  shall pay for diabetes screening once every 12 months for a beneficiary that is not pre -diabetic.  A/B MACs (A) shall pay for diabetes screening at a frequency of once every 6 months for a beneficiary that meets the definition of pre -diabetes.   A claim that is submitted for diabetes screening by a physician or supplier for a beneficiary that does not meet the definition of pre -diabetes shall be submitted in the following manner:   The line item shall contain 82947, 82950 or 82951 with an ICD -9-CM diagnosis code of V77.1 or, if ICD -10-CM is applicable, a diagnosis code of Z13 .1.  90.3.1 - Modifier Requirements for Pre -diabetes  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A claim that is submitted for diabetes screening and the beneficiary meets the definition of pre -diabetes shall be submitted in the following manner:   The line item shall contain 82497, 82950 or 82951 with a diagnosis code of V77.1 (if ICD -9-CM is applicable) or, if, ICD -10-CM is applicable, diagnosis code Z13.1.  In addition, modifier TS (follow -up service) - shall be reported on the line item.  90.4 - Diagnosis Code Reporting  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A claim that is submitted for diabetes screening shall include the diagnosis code V77.1 (if ICD -9-CM is applicable) or (if ICD -10-CM is applicable) diagnosis code Z13.1.   90.5 - Medicare Summary Notices (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  When denying claims for diabetes screening based upon a CWF reject for 82947, 82950 or 82951 reported with ICD -9-CM diagnosis code V77.1 or ICD -10-CM diagnosis code Z13.1, A/B MACs (A) and (B) shall use MSN 18.4, This service is being denied because it has not been 6 months since your last examination of this kind.  (See chapter 30 section 40.3.6.4(c) for additional information on ABNs.)   90.6 - Remittance Advice Remark Codes (Rev. 457, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05)  A/B MACs (A) and (B) shall use the appropriate remittance advice notice that appropriately explains the denial of payment.   90.7 - Claims Adjustment Reason Codes  (Rev. 457, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05)  A/B MACs (A) and (B) shall use the appropriate claims adjustment reason code such as 119 Benefit maximum for this time period or occurrence has been reached.   100 - Cardiovascular Disease Screening  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01 -03-05)  100.1 - HCPCS Coding for Cardiovascular Disease Screening  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01- 03-05)  The following HCPCS codes are to be billed for Cardiovascular Disease Screening:   80061 -  Lipid Panel  82465 -  Cholesterol, serum or whole blood, total  83718 -  Lipoprotein, direct measurement, high density cholesterol  84478 -  Triglycerides   100.2 - A/B MAC (B) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service, January 1, 2005, and later, A/B MACs (B) shall recognize the above HCPCS codes for Cardiovascular Disease Screening.   A/B MACs (B) shall pay for Cardiovascular Disease Screening once every 60 months.