New Medicare Preventive Services National Provider Call


Uploaded by CMSHHSgov on 23.10.2012

Transcript:
Welcome to this video slideshow presentation from the new Medicare
Preventive Services National Provider Call. Brought to you by the
Medicare Learning Network, your source for official CMS information for
Medicare Fee For Service Providers. This educational call was hosted by
the CMS Provider Communications Group within the Center for Medicare on
Wednesday August 15, 2012.
Hello. Im Leah Nguyen from the Provider
Communications Group here at CMS, and I will serve as your moderator for
todays call, which is brought to you by the CMS Medicare Learning
Network. I would like to welcome you to our National Provider Call on
the Five New Medicare Preventive Services: 1. Screening and behavioral
counseling interventions in primary care to reduce alcohol misuse, 2.
Screening for depression in adults, 3. Intensive behavioral therapy for
cardiovascular disease, 4. Screening for sexually transmitted infections
and high-intensity behavioral counseling to prevent STIs, and 5.
Intensive behavioral therapy for obesity.
CMS experts will provide an overview of these services, when to perform
them, how to perform each service, who is eligible, and how to code and
bill for each service.
Before we get started, there are few items that I need to cover. The
slide presentation for todays call was posted on the CMS Web site, and a
link to the presentation was e-mailed to all registrants earlier this
afternoon. The presentation can also be downloaded from the CMS
Fee-for-Service National Provider Calls Web page at www.cms.gov/npc.
Again, that URL is www.cms.gov/npc.
At the left side of the Web page, select National Provider Calls and
Events, and then select the August 15 call from the list. This call is
being recorded and transcribed. An audio recording and written
transcript will be posted soon to the National Provider Calls and Events
section of the CMS Fee-for-Service National Provider Calls Web page.
At this time, I would like to introduce our speakers for today. We are
pleased to have with us Michelle Issa, Jamie Hermansen, and Deirdre
OConnor from the Coverage and Analysis Group Center for Clinical
Standards and Quality; Kathy Bryant from the Hospital Ambulatory Policy
Group of the Center for Medicare; and Wil Gehne from the Provider
Billing Group of the Center for Medicare.
And now it is my pleasure to turn our call over to Michelle Issa for the
first presentation on Screening and Behavioral Counseling Interventions
in Primary Care to Reduce Alcohol Misuse. Thank you, Leah.
Effective October 14, 2011, Medicare will cover annual alcohol
screening, and for those that screen positive, Medicare covers up to
four brief, face-to-face behavioral counseling interventions annually
for Medicare beneficiaries, including pregnant women.
Next slide. Slide 8 is the Description of the Service and Our
Beneficiary Eligibility. * For those beneficiaries who screen positive,
Medicare covers up to four face-to-face behavioral counseling
interventions in a primary care setting. * For those who misuse alcohol
but whose levels or patterns of alcohol consumption do not meet criteria
for alcohol dependence. * For those who are competent and alert at the
time that counseling is provided. * Whose counseling is furnished by a
qualified primary care physician or other primary care practitioner in a
primary care setting.
CPT only copyright 2011 American Medical Association. All rights
reserved.
Next slide, number 9: Where Can Eligible Beneficiaries Receive These
Services and Who Can Provide Them Screening and behavioral counseling
intervention to reduce alcohol misuse must be furnished by a qualified
primary care physician or other primary care practitioners in a primary
care setting.
Next slide, slide number 10. For the purposes of this covered service,
a primary care practitioner is a physician with specialty designation of
general practitioner, family practice practitioner, general internist,
or obstetrician or gynecologist; a physician assistant; a nurse
practitioner; and a clinical nurse specialist. Thank you.
And Id like to turn this over to Kathy.
Im on slide 11. Under the Medicare Program for Code G0442, which is
what is used for annual alcohol misuse screening, the national payment
rate for physicians in a nonfacility setting, such as a physicians
office, would be $17.36. In a facility setting, it would be $9.19. And
the hospital outpatient OPPS rate would be $35.69. For all of these
services, there is no beneficiary co-insurance or deductible.
For G0443, which is the code that is used for each of the brief
face-to-face behavioral counseling sessions, the national payment rates
are $25.19 for the physician nonfacility setting, $23.15 for the
physician in a facility setting, and, again, $35.69 for the hospital
outpatient department. Again, there is no beneficiary co-insurance or
deductible.
While we are on the call, I also wanted to point out to you, in slide
number 12, a tool that is available on the Web site that youll be able
to use any time to check on these or any other physician payment rates
that you may be interested in. Its the Medicare Physician Fee Schedule
Search Tool, which you have the link for there, and at this tool, you
can put in any CPT or HCPCS code and get all kinds of information,
including not only the payment but the payment policy indicators
limiting charge, and we keep this updated at least quarterly so as when
we change rates or new codes are added, you can always check here and
get that information.
Im sorry, and now Id like to turn the call over to Wil. Thanks, Kathy.
On slide 14, we turn to Coding Professional Claims, and before I start,
I want to define a couple of terms just for claritys sake. When the
slide titles are referring to Professional Claims, thats referring to
claim formats, so that means claims that will be submitted on a CMS 1500
paper claim form or an electronic 837 professional (837P) format.
Each of my billing segments will talk about coding and editing of those
professional claims, and then coding and editing of institutional
claims, by which I mean claims submitted on the UB04 or the 837i
electronic format, and then Ill talk a little bit about editing of all
claims.
So going back to professional claims, we are using the two HCPCS codes
that Kathy mentioned, G0442 for screening and G0443 for behavioral
counseling. And Michelle had mentioned primary care practitioners in a
primary care setting, and we identify those things on professional
claims using a set of provider specialty types for determining primary
care practitioners, and theyre listed there on slide 14: general
practice, family practice, internal medicine, obstetrics and gynecology,
pediatric and geriatric medicine, certified nurse midwife, nurse
practitioner, certified clinical nurse specialist, and physician
assistant.
Turning to slide 15: The place of service codes that are used to
identify primary care settings for the service are: physicians office,
outpatient hospital, independent clinic, federally qualified health
center, public health clinic, and rural health clinic.
In terms of how Medicare Systems will edit professional claims, well
ensure that the two G codes are denied if theyre not billed with the
appropriate place of service code, as was defined, and those denials
will be identified on the remittance advicethe claim adjustment reason
code 58, defined as treatment was deemed by the payer to have been
rendered in an inappropriate or invalid place of service, and remittance
advice remark code N428, service/procedure not covered when performed in
certain settings.
Similarly, when either code is not billed with one of the defined
specialty provider specialties, the remittance advice for denials will
be identified with reason code 185 (rendering provider is not eligible
to perform this service billed), and remark code N95 (the provider
type/provider specialty may not bill this service). Thats on slide 17.
Turning to slide 18, we get the coding for institutional claims the
same two HCPCS codes, G0442 and G0443. We use them on institutional
claims. On institutional claims, we are identifying primary care
setting by a specific list of types of bill: type of bill 13x for
outpatient hospital, 71x for rural health clinic, 77x for federally
qualified health centers, and 85x for critical access hospital
outpatient.
On slide 19, editing institutional claims were similarly ensuring that
the two G codes are billed with one of the types of bill I just
mentioned, and denials for using other types of bill will be identified
under remittance advice with reason code 5 (the procedure code bill type
is inconsistent with the place of service) and remark M77 (for invalid
place of service).
Next, slide 20. As the facilities in the audience will be familiar, the
Medicare payment basis for institutional claims, you know, varies by the
facility type: hospital outpatient claims, paid under the Outpatient
Prospective Payment System; RHC and FQHC claims paid under all-inclusive
payment rate; and critical access hospital claims paid based on the
payment method thats selected by the hospital. If they select method I,
we pay 101 percent of reasonable cost for technical component of the
service, with the professional component able to be billed separately,
and if they elect method II, 101 percent of the reasonable cost for the
technical component plus 115 percent of the nonfacility rate for the
professional component of those services.
And any time we have payments that are covered by an all-inclusive rate,
as in our RHC and FQHC settings, we have the question of what can be
paid separately from an encounter or what is bundled into the payment
for an encounter. So turning to slide 21, there are some special
instructions for RHC/ FQHC payment, and that is that the alcohol
screening and counseling is usually not separately payable with another
encounter or visit on the same date. So on those claims, a separate
service line is reported so that we can carve out the charges from the
co-insurance and deductable, which Kathy mentioned dont apply to the
service, but Medicare systems will bundle the line with the encounter
and share that on the remittance advice with reason code 97, indicating
that thee benefit for this service is included in the payment for
another service.
Turning to slide 22 a couple of terms, additional terms to define, when
we talk about frequency editing in the slides that follow. By
professional services, we mean any professional claim as I defined them
earlier, plus any institutional claims thats billed with RHC or FQHC
bill types, or institutional claims with the type of bill 85x that show
institutional service revenue codes revenue codes 096x, 097x, or 098x.
Facility fee claims will be, you know, pretty much anything thats left
types of bill 13x and 85x, where the professional service revenue codes
are not reported.
Slide 23 turns to editing that applies to both professional and
institutional claims. All claims for these services well be editing to
ensure that G0442 is not billed more than once in a 12-month period, and
G0443 is not billed more than four times in a 12-month period. And the
remittance advice coding for those denials that exceed those maximums
would be reason code 119, which is benefit maximum for this period has
been reached, or the remark code N362, which is the number of days or
units exceed our acceptable maximum. For each of those limits, a
professional service or facility fee, as I described them, can be billed
separately.
Slide 24 describes editing to ensure that G0443 is not billed more than
once on the same date of service for the same beneficiary, and denials
for that reason will be identified on remittance advices with reason
code 151, payment adjusted because the payer deems the information
submitted does not support this many of the frequency of services and
remark code M86, service denied because the payment is already made for
a similar procedure within the set timeframe.
And finally, turning to slide 25: We will also edit to ensure that the
screening code G0442 is in the beneficiarys paid claims history before
any claims for G0443 can be paid, and if that condition isnt met, the
remittance advice will be coded with claim adjustment reason code B15,
the service requires that qualifying service be received and covered,
the qualifying service has not been received or adjudicated, and remark
M16 with an alert to see the contractors Web site for the details,
(inaudible), regarding this. Leah
Thank you, Wil. Theres a list of resources for Screening and Behavioral
Counseling Interventions in Primary Care to Reduce Alcohol Misuse on
slide 26. And now I would like to turn the call back over to Michelle
Issa, with our presentation on Screening for Depression in Adults.
Thanks, Leah.
Effective October 14, 2011, Medicare covers annual screening for adults
for depression in a primary care setting that have staff-assisted
depression care supports in place to assure accurate diagnosis,
effective treatment, and followup.
Next slide, number 29. Screening up to 15 minutes for depression
screening for Medicare beneficiaries in a primary care setting when
staff-assisted depression care supports are in place to assure accurate
diagnosis, effective treatment, and followup. At a minimum level,
staff-assisted supports consist of a clinical staff for example, a
nurse or physician assistant in a primary care setting who can advise
the physician of screening results and who can facilitate and coordinate
referrals to mental health treatment.
Various screening tools are available for screening for depression. CMS
does not identify specific depression screening tools. Rather, the
decision to use a specific tool is at the discretion of the clinician in
a primary care setting. Next slide, number 30. For the purposes of this
benefit, a primary care setting is a setting where there is provision of
integrated, accessible healthcare services by clinicians who are
accountable for addressing large majority of personal health care needs,
development of sustained partnership with patients, and practicing in
the context of family and community.
Next slide, Coverage Limitations, slide 31. Screening for depression is
not covered when performed more than one time in a 12-month period. It
does not include treatment options for depression or any diseases,
complications, or chronic conditions resulting from depression, nor does
it address therapeutic interventions such as pharmacotherapy,
combination therapy, counseling and medications, or other interventions
for depression. Self-help materials, telephone calls, and Web-based
counseling are not separately reimbursable by Medicare and are not part
of this national coverage determination.
Thank you. Now Id like to turn it over to Kathy.
Thank you.
For HCPCS code G0444 is the code used for annual depression screening.
The national payment rates, again, starting with the physician
nonfacility rate is $17.36. For the physician providing a service in
the facility, $9.19. The hospital outpatient rate is $35.69. And there
is no beneficiary co-insurance or deductible for this service.
Now, Ill turn it over to Wil.
Thanks, Kathy.
For coding of depression screening on professional claims, you would use
HCPCS Code G0444, and in this case the associated place of service code
list is a little bit more limited limited to physicians office,
outpatient hospital, independent clinic, or public health clinic.
Similar to the other benefits, the Medicare system is going to edit to
ensure that the correct place of service is reported, and if its not,
the remittance advice will show that with reason code 58 and the remark
code N428. And for the place of service edits, the remittance advice
coding is consistent across all five of these benefits. Well move
through that a little bit more quickly as we go along.
Regarding coding institutional claims, the same HCPCS would be used, and
the same list of type of bills is allowable that we had seen in the
previous benefits and Medicare systems (turning to slide 36) and, again,
edit to ensure that. In this case, we have slightly different
remittance advice coding for those denials using reason code 170, which
is that payment is denied when performed or billed by this type of
provider, and remark code N428, not covered when performed in this place
of service. So for the institutional claim edits, the remittance advice
coding varies slightly between the benefits.
Once again, the payment basis on slide 37 varies by facility type. This
is consistent across all five of the benefits. Well move through that a
little bit more quickly as we go along as well.
Turning to all claims again on slide 38: Medicare systems enforce that
annual depression screening is billed no more than once within a
12-month period. Whenever there are time limitations like that its
important to get the specific definition of how thats enforced, and were
using 11 full months that must elapse following the month in which the
last annual depression screening took place.
On slide 39, you can see that when that edit is applied, the remittance
advice will indicate it with reason code 119, benefit maximum for this
time period or occurrence has been reached, and remark code N362, the
number of days or units of service exceeds our acceptable maximum. And
once again, professional and facility fees can be billed separately for
the services just as we defined them back on slide 22.
Leah
Ill now turn the call over to Jamie Hermansen with our presentation on
Intensive Behavioral Therapy for Cardiovascular Disease. Thank you,
Leah.
Effective November 8, 2011, Medicare covers intensive behavioral therapy
for cardiovascular disease, which is also referred to as a CVD risk
reduction visit. The visit consists of three components: 1. Encouraging
aspirin use for primary prevention of cardiovascular disease, 2.
Screening for high blood pressure, and 3. Intensive behavioral
counseling to promote a healthy diet. Medicare covers one face-to-face
CVD risk reduction visit each year.
On slide 43, Medicare Part B covers the CVD risk reduction visit for
Medicare beneficiaries who are competent and alert at the time
counseling is provided and whose counseling is furnished by a qualified
primary care physician or primary care practitioner and in a primary
care setting.
Slide 44. For purposes of this covered benefit, a primary care
practitioner is a physician with a specialty designation of general
practitioner, family practice practitioner, general internist,
obstetrician or gynecologist, physician assistant, nurse practitioner,
or clinical nurse specialist.
Slide 45. For purposes of this covered benefit, a primary care setting
is defined as one in which there is a provision of integrated,
accessible healthcare services by clinicians who are accountable for
addressing a large majority of personal health care needs, developing a
sustained partnership with patients, and practicing within the context
of family and community.
I would now like to hand the call over to Kathy Bryant.
For the intensive behavioral therapy to reduce cardiovascular disease,
individual, face-to-face counseling, you use code G0446. The national
payment rates for the physician in an office or other nonfacility
setting is $25.19, for a physician in a facility setting is $23.15, and
for the hospital outpatient department is $35.69. There is no
beneficiary co-insurance or deductible.
Now, Ill turn it over to Wil.
Thanks, Kathy.
Turning to slide 47 regarding professional claims: Youd use the HCPCS
code that Kathy just mentioned, G0446, and in this case, one of the
provider specialty types from the longer list that we saw on the alcohol
NCD I dont want to read the entire list again, but you have it there on
slide 47.
And on slide 48, the same list of place of service codes that we saw on
the last benefit.
Slide 49: Again, its very consistent. We have the same two edits for
ensuring that those provider specialty types and places of service are
reported, and the remittance advice coding for those two denials is
identical to the two that we saw before.
Regarding institutional claims on slide 50, use G0446 and one of the
whats now a familiar looking list of types of bill, that you see there
on slide 50.
And on slide 51, well be editing to ensure that service is limited to
those types of bill, and coding the remittance advice for any denials
with reason code 170 and remark code N428.
Slide 52: Once again, the payment varies, and the information there is
similar to what you saw, or identical to what you saw, on the earlier
slide.
Slide 53, regarding editing of all claims for Medicare systems, well be
editing to ensure that the G0446 is billed no more than once in a
12-month period using that same criterion of 11 full months following
the service month, and well be coding remittance advice for denials in
the same way that we did for the depression screening, with reason code
119 and remark code N362. And once again, professional and facility fees
can be billed separately for the service.
Leah
Thank you, Wil.
Theres a list of resources for intensive behavioral therapy for
cardiovascular disease on slide 54. I will now turn the call over to
Deirdre OConnor for our presentation on screening for sexually
transmitted infections and high-intensity behavioral counseling to
prevent STIs. Hi. On slide 56, there is the description of the service.
So, effective for dates of service on or after November 8, 2011, CMS
will cover screening for sexually transmitted infections specifically
chlamydia, gonorrhea, syphilis, and hepatitis B with the appropriate
Food and Drug Administrationapproved/cleared laboratory tests when
ordered by the primary care provider.
The tests must be used consistent with FDA-approved labeling and in
compliance with the Clinical Laboratory Improvement Act regulations and
performed by an eligible Medicare provider for these services.
Who is covered and frequency
Screening for chlamydia and gonorrhea: Pregnant women who are 24 years
old or younger when the diagnosis of pregnancy is known, and then repeat
screening during the third trimester if high-risk sexual behavior has
occurred since the initial screening test, Pregnant women who are at
increased risk for STIs when the diagnosis of pregnancy is known, and
then repeat screening during the third trimester if high-risk sexual
behavior has occurred since the initial screening test, and Women at
increased risk for STIs, annually.
For syphilis: Pregnant women when the diagnosis of pregnancy is known,
and then repeat screening during the third trimester and at delivery if
high-risk sexual behavior has occurred since the previous screening
tests, Also, men and women at increased risk for STIs annually.
For hepatitis B: Pregnant women at the first prenatal visit when the
diagnosis of pregnancy is known, and then re-screening at the time of
delivery for those with new or continuing risk factors.
The coverage policy for the high intensity behavioral counseling is
effective for dates of service on or after November 8, 2011. CMS will
cover individual, 20- to 30-minute, face-to-face counseling sessions for
Medicare beneficiaries for high-intensity behavioral counseling to
prevent STIs, if referred for this service by a primary care provider
and provided by a Medicare-eligible primary care provider in a primary
care setting.
Slide 61, Description of Primary Care Practitioner. Primary care
practitioner is described as a physician with a specialty designation of
general practitioner, family practice practitioner, general internist,
or obstetrician or gynecologist; physician assistant, nurse
practitioner, or clinical nurse specialist.
A setting where there is a primary care setting is described as
provision of integrated, accessible healthcare services by clinicians
who are accountable for addressing a large majority of personal health
care needs, development of sustained partnership with patients, and
practicing in context of family and community.
Slide 63 is high-intensity behavioral counseling is defined as a
program intended to promote sexual risk reduction or risk avoidance,
which includes each of these broad topics, allowing flexibility for
appropriate patient-focused elements: education, skills training, and
guidance on how to change sexual behavior. The medical record should be
a reflection of the service provided, and I would refer you to the MLN
Matters article on National Coverage Determination on slide 80 for a
complete description of who is considered at high or increased risk.
CMS will cover up to two individual, 20- to 30-minute, face-to-face
counseling sessions annually for all sexually active adolescents and for
adults at increased risk for STIs.
And now, Ill hand it over to Kathy.
Thank you.
For the high-intensity behavioral counseling to prevent sexually
transmitted infections, you use code G0445, and that code includes
education, skills training, and guidance on how to change sexual
behavior. The national payment rates for each of those services: for a
physician in a nonfacility setting, $25.19; for a physician in a
facility setting, $23.15; and the OPP hospital outpatient rate is
$35.69. There is no beneficiary co-insurance or deductible for these
services.
Now, Ill turn it over to Wil. Oh wait, Im sorry. I wont turn it over to
Wil. I also wanted to mention that for the screening, the clinical lab
tests are also covered for chlamydia, gonorrhea, syphilis, and hepatitis
B. Those are paid under the clinical lab fee schedule, and on slide 66
weve provided you with the link to get that exact information, depending
upon the (inaudible) you would be using.
And now, Ill turn it over to Wil.
Thanks, Kathy.
Starting at slide 67, regarding coding professional claims, youd use the
G0445 code that Kathy mentioned, and for this service we have an
additional requirement, that the reporting HCPCS code needs to be
supported by a specific ICD-9 diagnosis code, and that is code V69.8.
At the bottom of slide 67, you see the now-familiar list of provider
specialty types that are required, and again on slide 60 Im sorry, on
67 you see that, and again on 68, you see the list of place of service
codes that are accepted.
Slide 69 indicates that, once again, were editing to ensure that those
specialty types and places of service are reported accurately on the
claim, and the remittance advice coding is consistent with what weve
talked about before.
Regarding coding institutional claims, on slide 70, the same HCPCS code
is used, and the same ICD-9 code requirement for V69.8 applies. The
familiar list of types of bill is in effect here as well, and on slide
71, you see that the remittance advice coding for any denials for other
types of bill uses reason code 170 and remark code N428.
Once again, on slide 72, the payment varies by facility type, and the
special instructions for RHCs and FQHCs apply.
For editing of all claims, we ensure that the G0445 is billed with the
diagnosis code V69.8, and denials for the absence of that diagnosis code
will be reported with reason code 50. Theyre not these are noncovered
services because this is not deemed a medical necessity by the payer,
and remark code N386, indicating that this physician was based on a
national coverage determination.
Well also be editing to ensure that G0445 is billed no more two sessions
in a 12-month period, and any denials for that reason will be coded
using the benefit maximum codes that weve seen earlier in the
presentation. And once again, facilities are professional services and
facility fees can be billed separately when applying those frequency
limitations.
For this service, as Kathy mentioned, we have coding for laboratory
billing as well, and I dont want to read the long list of HCPCS codes
that are shown on slide 75, but note that there are nine different codes
for chlamydia testing, four for gonorrhea, three for syphilis, two for
hepatitis B, and those HCPCS code can be supported by ICD-9 codes V74.5,
V73.89, V69.8, V22.0, V22.1, or V23.9.
A list of valid ordering provider specialties for those lab codes is
similar to the list of identical to the list of provider specialties
that weve seen on several of the other services and shown on slide 76.
Medicare systems edits to the laboratory billing will be ensuring that
the STIs are billed with the appropriate ICD-9 diagnosis code that I
just mentioned, and denials for the lack of these diagnostic codes would
use reason code 50 and remark code N386.
On slide 78, well be ensuring that the ordering physician specialty is
appropriate for screenings for STIs, and those denials would be
indicated on remittance advice with reason code 184, the prescribing or
ordering provider is not eligible to prescribe or order the service
billed.
On slide 79 notes that well also be editing to ensure that those
screenings for STIs do not exceed coverage frequency limitations as they
had noted with coverage frequency differs based on the test performed,
patient gender, high-risk diagnosis, and pregnancy status, and the
benefit maximum remittance advice coding that weve seen on earlier
slides applies to these services as well.
Leah
Thank you, Wil. And again, theres a list of resources for screening for
sexually transmitted infections and high-intensity behavioral counseling
to prevent STIs on slide 80.
I will now turn the call over to Jamie Hermansen for our final
presentation on intensive behavioral therapy for obesity.
Thank you, Leah.
On slide 82: Effective November 29, 2011, Medicare covers intensive
behavioral therapy for obesity for beneficiaries with a body mass index
greater than or equal to 30. Intensive behavioral therapies for obesity
consist of the following: a screening for obesity in adults using
measurement of BMI calculated by dividing weight in kilograms by the
square of height in meters, dietary nutritional assessment, and
intensive behavioral counseling and behavioral therapy to promote
sustained weight loss through high-intensity interventions on diet and
exercise.
On slide 83: For Medicare beneficiaries with obesity who are competent
and alert at the time that counseling is provided and whose counseling
is furnished by a qualified primary care physician or other primary care
practitioner and in a primary care setting, CMS covers one face-to-face
visit every week for the first month, one face-to-face visit every other
week for months 2 through 6, and one face-to-face visit every month for
months 7 through 12, if the beneficiary meets the 3 kg weight loss
requirement during the first six months.
For slide 84: At the six-month visit, a reassessment of obesity and a
determination of the amount of weight loss must be performed.
Beneficiaries must lose 3 kg during the first six months of counseling
to be eligible for counseling for an additional six months.
Beneficiaries who do not achieve a weight loss of 3 kg or more may
undergo reassessment of their readiness to change and BMI after an
additional six months period.
On slide 85: This service must be furnished in a primary care setting
by a primary care practitioner.
For slide 86: For purposes of this covered benefit, a primary care
practitioner is a physician with specialty designation of general
practitioner, family practice practitioner, general internist,
obstetrician or gynecologist; a physician assistant, nurse practitioner,
or clinical nurse specialist.
For slide 87: For purposes of this covered benefit of primary care
setting is to find those one in which the provision of integrated,
accessible healthcare services by clinicians who are accountable for
addressing a large majority of personal health care needs, developing a
sustained partnership with patients, and practicing within the context
of family and community.
For slide 88 and 89: The decision the decision covers intensive
behavioral therapy for obesity when furnished in primary care settings,
as described in Section 210.12 of the Medicare National Coverage
Determinations Manual. In the primary care office setting, Medicare may
cover these services when billed by the primary care physician or
practitioner and furnished by auxiliary personnel under the conditions
specified under our regulation at 42 CFR section 410.26(b). In the
primary care hospital outpatient setting, Medicare may cover these
services when furnished and billed by the primary care physician or
practitioner, as described in Section 210.12 of the Medicare National
Coverage Determinations Manual.
In addition, Medicare may cover these services when furnished by the
hospital in outpatient hospital settings under the conditions specified
under our regulation at 42 CFR 410.270. We believe that providing for
coverage under these conditions will promote appropriate staff to
furnish intensive behavioral therapy for obesity while ensuring that
services are delivered within the primary care setting in order to
provide a coordinated approach as part of each patients comprehensive
prevention plan.
I would now like to hand the call over to Kathy Bryant.
Thank you. For the face-to-face behavioral counseling for obesity, use
code G0447. For physician rates in a nonfacility setting, it is at
$25.19; for the physician rate in a facility setting, its $23.15; and
for the OPPS rate, it is $35.69. There is no beneficiary co-insurance
or deductible for this service.
Now, Ill turn it over to Wil.
Thanks, Kathy.
When coding professional claims using the G0447, once again there is a
diagnosis coding requirement. In this case, a range of codes one of a
range of codes must be used, all indicating body mass index is over 30
thats V85.30 through 39, or V85.41 through 45 and again those services
the combination of procedure and diagnosis codes needs to be billed by
one of the provider types I mean provider specialty types thats shown
on slide 90, and by one of the places of services codes place of
service codes, thats shown on slide 91.
Well be editing to ensure the specialty types and place of service codes
on slides 92 and 93 using the same remittance coding that has been
consistently applied for all the benefits weve talked about today.
On slide 94, Coding Institutional Claims: The same requirement for a
HCPCS code and a code from the diagnosis range of V85.30 through 39 or
V85.41 through 45 applies, and the familiar list of types of bill must
be used.
When Medicare systems are editing to ensure institutional claims are
using the appropriate type of bill for this service, the remittance
advice coding varies back to using adjustment reason code 5 and remark
code M77.
And once again on slide 96, the payment for the service varies by the
type of bill.
On slide 97: Medicare claim system edits that apply to all claims were
ensuring that G0447 is billed with one of those specified diagnosis
codes, and remittance advice codes for denial are reason code 167, these
diagnosis codes are not covered, and remark code N386, indicating that
the decision was based on a national coverage determination.
Were also editing, on slide 98, to ensure the frequency limitation.
Jamie described the frequency limitation varies over time by month, and
because we cant be sure in Medicare systems that services are coming in
sequentially, we cant enforce that requirement exactly, but we can sure
enforce systematically that the absolute limit for a 12-month period is
met, and so were ready to ensure that G0447 is billed no more than 22
times during a 12-month period, and if that condition is exceeded that
limit is exceeded, using the benefit maximum remittance advice coding
that weve seen several times in the earlier presentation.
One last thing Id like to note, and this applies to all five of the
benefits weve talked about today, next eligible dates for the services
that have been described are viewable through standard inquiry methods.
So if youre not certain whether a beneficiary is eligible on a given
date, you can check through one of the standard inquiry methods and get
the date that is appropriate.
Thanks.
Thank you, Wil.
Theres a list of resources for intensive behavioral therapy for obesity
on slide 100.
On slide 101, we have information on how to submit comments for the
calendar year 2013 Physician Fee Schedule proposed rule, and on slide
102 theres a list of general preventive services resources.
Thank you for viewing this Medicare Preventive Services Video Slideshow
Presentation. The information presented in this presentation was correct
as of the date it was recorded. This presentation is not a legal
document. Official Medicare program legal guidance is contained in the
relevant statutes, regulations, and rulings.