Health Information Management

Take steps to prepare for new Medicare preventive screening benefit

APCs Insider, January 5, 2007

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Take steps to prepare for new Medicare preventive screening benefit

QUESTION: Could you tell me about the new preventive screening benefit from CMS?

ANSWER: CMS added a new benefit effective January 1, 2007: A screening ultrasound for abdominal aortic aneurysms (AAA). However, CMS implemented several limitations and restrictions upon the new benefit that you should share with your coding/billing staff.

You must report the new benefit using new HCPCS code G0389 (ultrasound, B-scan and/or real time with image documentation; for AAA screening). FIs will pay for the service under the OPPS, staff furnishes the service to hospital outpatients and hospitals submit the service on type of bill 12X or 13X.

For medical necessity and reimbursement, the patient must meet the following criteria:

  • Receive a referral for the ultrasound screening benefit as a result of an initial preventive physical exam (IPPE). This is the crucial piece for hospitals to remember. If the patient does not qualify for the IPPE, they do not qualify for this benefit.
  • Receive the screening from an authorized provider/supplier of ultrasound diagnostic services.
  • Not have received an ultrasound screening for AAA under the Medicare program.

In addition, the patient must have at least one of the following risk factors:

  • Have a family history of abdominal aortic aneurysms
  • Be a man aged 65 to 75 years who has smoked at least 100 cigarettes in his lifetime
  • Be a beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and Human Services' national coverage determination process

For more information on the new benefit, including ABN guidance, go to the CMS Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5235.pdf.



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