Corporate Compliance

Note from the Instructor: CMS releases updated educational tool on coverage, billing and payment for preventive services

Medicare Insider, April 7, 2015

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This week’s note from the instructor is written by Judith L. Kares, JD, regulatory specialist for HCPro.  
In its April 2, 2015 MLN Connects Provider ENews, CMS released a revised “Preventive Services” Educational Tool (ICN 006559), which is now available in a user-friendly interactive format. This revised resource is designed to provide information on Medicare-covered preventive services, including related guidelines on coverage, billing and payment. Let us review the information available to those who utilize this new tool.
Information available
In the updated “Preventive Services” Educational Tool, CMS provides the following information on Medicare preventive services:
  • Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes;
  • International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes;
  • Coverage requirements;
  • Frequency limitations; and
  • Beneficiary liability for each Medicare preventive service.
CMS also indicated which of the listed preventive services can be delivered via telehealth.
The updated tool contains relevant information for 26 preventive services, listed in alphabetical order, ranging from Alcohol Misuse Screening and Counseling to Ultrasound Screening for AAA. 
Below is an example of the information available for one of the listed services:
Alcohol Misuse Screening and Counseling (Also referred to as the Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse)
G0442 – Annual alcohol misuse screening, 15 minutes
G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
ICD-9-CM Codes
No specific diagnosis code
   Contact local Medicare Administrative Contractor (MAC) for guidance
Who Is Covered
All Medicare beneficiaries are eligible for alcohol screening.
Medicare beneficiaries who screen positive (those who misuse alcohol but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence) are eligible for counseling if:
  • They are competent and alert at the time that counseling is provided; and
  • Counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.
  • Annually for G0442; or
  • For those who screen positive, 4 times per year for G0443
Beneficiary Pays
  • Copayment/coinsurance waived
  • Deductible waived
CMS also provides additional guidance in the form of Frequently Asked Questions and a listing of related resources. The tool permits users to print individual or complete guidelines.
Assistance with limitation on liability and hospital outpatient notification process
In particular, this tool may aid hospitals with their outpatient notification process when limitation on liability (LOL) applies. LOL requires hospitals to notify beneficiaries when they believe certain outpatient services ordered by practitioners will not be covered under Medicare because those services:
  • fail to meet Medicare’s medical necessity guidelines for the patient’s condition;
  • are screening or preventive services subject to frequency limitations;
  • are custodial in nature; or
  • are experimental or for research purposes.
Many preventive services included in this educational tool are subject to frequency limitations, as well as other coverage requirements. Medicare only provides coverage for specific preventive services so long as those services are not provided more frequently than their respective frequency limitations and meet other applicable coverage guidelines. 
For example, once a beneficiary has reached the age of 40, the frequency limitation for coverage of a screening mammography is 11 full months after the last covered screening mammography. If a beneficiary has a screening mammography in April 2015, she will not be eligible for another covered screening mammography until April 1, 2016.
When a hospital believes that certain services (including those subject to frequency limitations) will not be covered because LOL applies, it is required to notify the beneficiary prior to the performance of the service that the hospital will look to the beneficiary for payment if:
  • he or she has the services performed; and
  • Medicare denies payment.
The current form of required notification is the Advanced Beneficiary Notice of Noncoverage (ABN). 
In this user-friendly interactive educational tool, CMS has pulled together relevant coverage information on preventive services, making it much easier for hospitals using this tool to implement an appropriate ABN process with respect to these services.
CMS email update subscriptions
If they have not already done so, hospitals are encouraged to subscribe to CMS email updates, including the MLN Connects Provider ENews, through the Email Updates web site. The site can be accessed through the “CMS Email Update Lists – Subscriber’s Main Page” link on HCPro’s links page. The MLN Connects Provider ENews is published every Thursday and contains valuable information on MLN national provider calls and events; CMS announcements; claims, pricer and code updates; and MLN educational products.

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