Download Preventive Services

Preventive
Services
MANUAL
www.cahabagba.com
Cahaba
JJ A/B Medicare Administrative
Contractor
Provider Outreach and Education
Medicare Part B
Alabama • Georgia • Tennessee
December 2015
Disclaimer
This instructional material was prepared as a service to the public and is not intended to
grant rights or impose obligations. This instructional material may contain references or
links to statutes, regulations or other policy materials. The information provided is only
intended to be a general summary. It is not intended to take the place of either the written
law or regulations. We encourage readers to review the specific statutes, regulations and
other interpretive materials for a full and accurate statement of their contents.
Cahaba, their employees, and their staff make no representation, warranty, or guarantee
that this compilation of Medicare information is error-free, nor that the use of this manual
will prevent differences of opinion or disputes with the Medicare Contractor as to the
codes that are accepted or the amounts that will be paid to providers of services, and will
bear no responsibility for the results or consequences of the use of this manual.
The information in this handbook is date-sensitive, and portions of the handbook may not
be accurate or relevant due to changes in policies, procedures, and regulations. Users are
urged to refer to the CMS website and the Cahaba website for the most current Medicare
policies, procedures and regulations.
2
Introduction
Welcome to the Preventive Services Manual. Cahaba has developed this educational
material to assist Medicare Part B providers/suppliers in locating laws, regulations,
policies and other guidelines directly related to your specialty.
CMS Internet Online Manual System
The CMS Internet Online Manual System is used by CMS program components,
partners, contractors, and State Survey Agencies to administer CMS programs. It offers
day-to-day operating instructions, policies, and procedures based on statutes, regulations,
guidelines, models and directives. The direct link to the CMS Internet Online Manual
System is http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-OnlyManuals-IOMs.html. Several of the web site links in this manual will direct you to the
Centers for Medicare and Medicaid Services (CMS) web site to help assure that you will
have the most current information.
On the following page, you will locate links to various educational materials. When you
locate a topic that you would like to review and the reference is to the CMS Online
Manual, please note the section number and click on the web site link. The web site link
will take you directly to the CMS Online Manual, publication and chapter. Scroll down
and review the appropriate section number.
3
Preventive Services Specialty Manual
CMS, Internet Only Manual, Pub. 100-04, Medicare Benefit Policy
Manual
Chapter 18 – Preventive Services
http://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/clm104c18.pdf
Medicare Learning Network Preventive Services Dedicated Webpage
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/PreventiveServices.html
2015 CMS Preventive Services Chart
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPSQuickReferenceChart-1TextOnly.pdf
CMS – Transmittals and Medicare Learning Network (MLN) Matters
Articles (2011-2015)
MM7012
Waiver of Coinsurance and Deductible for Preventive Services, Section
4104 of the Affordable Care Act, Removal of Barriers to Preventive Services in Medicare
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7012.pdf
MM7610
Screening for Sexually Transmitted Infections (STIs) and High Intensity
Behavioral Counseling (HIBC) to Prevent STIs
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7610.pdf
MM7633
Screening and Behavioral Counseling Interventions in Primary Care to
Reduce Alcohol Misuse
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7633.pdf
MM7636
Intensive Behavioral Therapy (IBT) for Obesity
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7636.pdf
4
MM7637
Screening for Depression in Adults
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7637.pdf
MM7641
Intensive Behavioral Therapy (IBT) for Obesity
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7641.pdf
MM7791
Contractor and Common Working File (CWF) Additional Instructions
Related to Change Request (CR) 7633 - Screening and Behavioral Counseling
Interventions in Primary Care to Reduce Alcohol Misuse
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7791.pdf
MM8874
Preventive and Screening Services — Update - Intensive Behavioral
Therapy for Obesity, Screening Digital Tomosynthesis Mammography, and Anesthesia
Associated with Screening Colonoscopy
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8874.pdf
MM8874-Updated April 3, 2015 Preventive and Screening Services — Update - Intensive
Behavioral Therapy for Obesity, Screening Digital Tomosynthesis Mammography, and
Anesthesia Associated with Screening Colonoscopy
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8874.pdf
SE 1013
Summary of Medicare Reporting and Payment of Services for Alcohol
and/or Substance (Other than Tobacco) Abuse Structured Assessment and Brief
Intervention (SBIRT) Services
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1013.pdf
SE 1431
Influenza Resources for the 2014-2015 Flu Season
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1013.pdf
5
General Billing Information
Medicare pays for reasonable and necessary services for the diagnosis and treatment of an illness
or injury. Although the law generally precludes payment for preventive services, Congress has
specifically legislated coverage for certain preventive services.
Medicare covers preventive health services in order to keep beneficiaries healthy. These services
are provided based on age, gender, and medical history. If results of any of the screening
examinations indicate that further tests are needed, the additional tests would be considered
diagnostic. The following preventive services are covered:
• Bone
Mass Measurement
• Cardiovascular
• Colorectal
• Diabetes
• Flu
Screening
Cancer Screening
Screening
(Influenza) Injections
• Glaucoma
• Hepatitis
• Initial
Screening
B Injections
Preventive Physical Examination
• Mammography Screening
• Medical
Nutrition Therapy
• Pneumococcal Pneumonia Vaccination (PPV)
• Prostate
Cancer Screening
• Screening Pap
Smears
• Screening Pelvic
• Smoking and
Examinations
Tobacco-Use Cessation
6
• Ultrasound
Screening for Abdominal Aortic Aneurysm
Medicare pays for a full range of preventive services and screenings. The Centers for Medicare
& Medicaid Services (CMS) recognizes the crucial role that health care professionals play in
promoting, providing, and educating Medicare patients about potentially life-saving preventive
services and screenings.
Screenings
Colorectal Cancer Screening
Medicare will cover colorectal cancer screening test/procedures for the early detection of
colorectal cancer. This coverage is subject to certain coverage, frequency, and payment
limitations. Medicare will waive the annual Medicare Part B deductible for colorectal
cancer screening for certain codes.
Prostate Cancer Screening
Medicare will cover prostate cancer screening test(s)/procedure(s) for the early detection
of prostate cancer subject to certain coverage, frequency, and payment limitations.
Diabetes Screening Tests
Diabetes screening laboratory tests are covered for persons at risk for developing diabetes
subject to certain coverage, frequency, and payment limitations.
Cardiovascular Screening Tests
Cardiovascular screening tests are covered for all Medicare beneficiaries. Coverage
includes tests for total cholesterol, high-density lipoprotein and triglycerides once every 5
years. There is no deductible or coinsurance.
7
Glaucoma Screening
Medicare provides coverage of annual glaucoma screening for individuals at high risk for
glaucoma including African Americans age 50 or older, individuals with a family history
of glaucoma, Hispanic Americans age 65 or over and individuals with diabetes.
Bone Mass Measurements
Coverage is provided for bone mass measurement procedures, including a physician’s
interpretation of the results.
Screening Pap Smear Coverage
Screening Pap smears are covered when ordered and collected by a doctor of medicine or
osteopathy or other authorized practitioner (e.g., a certified nurse midwife, physician
assistant, nurse practitioner, or clinical nurse specialist, who is authorized under state law
to perform the examination). The Part B deductible for screening Pap smear services paid
under the physician fee schedule is waived.
Screening Pelvic Examination
Medicare Part B pays for a screening pelvic examination if it is performed by a doctor of
medicine or osteopathy, or by a certified nurse midwife, a physician assistant, nurse
practitioner, or clinical nurse specialist who is authorized under State law to perform the
examination. This examination does not have to be ordered by a physician or other
authorized practitioner. The Part B deductible for screening pelvic examinations is
waived.
Screening Mammography
Medicare Part B provides coverage for a screening mammography when performed by a
certified provider. A screening mammography is a routine radiologic procedure furnished
8
to a woman without signs or symptoms of breast disease, for the purpose of early detection
of breast cancer, and includes a physician's interpretation of the results for the procedure.
Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
Medicare will pay for a one-time ultrasound screening for AAA for beneficiaries who meet
certain conditions.
Welcome to Medicare Physical Exam
Coverage is provided for a Welcome to Medicare Physical Exam, also referred to as the
Initial Preventive Physical Examination (IPPE). Beneficiaries enrolled in Medicare prior to
January 1, 2005 are not eligible for this service.
Smoking and Tobacco-Use Cessation Counseling Services
Medicare covers intermediate and intensive cessation counseling subject to eligibility and
frequency restrictions
For further information, also please see the CMS Internet Manual, Publication 100-4,
Chapter 18 and the “Prevention” links found on the CMS website
CMS has created an information website resource to help support the delivery and
promotion of Medicare preventive benefits.
CMS also developed The Guide to Medicare preventive Services for Physicians, Providers,
Suppliers, and Other Health Care Professionals to assist the health care community as part
of a comprehensive provider education program on preventive services and screenings
covered by Medicare. This publication includes coverage, coding, billing, and
reimbursement information on the following benefits covered by Medicare:
9
Cahaba University
An educational program designed to provide a broad variety of Medicare related training
to meet the needs of Medicare health care providers and suppliers. It is provides
centralized management and access to content created by the Provider Outreach and
Education department for the provider community. You will find the most commonly
viewed courses along with our educational recordings.
Resource Center for New Providers
A dedicated web page for those individuals who are new to the Medicare program or to
billing claims to Cahaba GBA. This page contains basic information and resources to get
you started.
Medicare B Newsline
The Cahaba GBA Medicare B Newsline serves as your official notice of Medicare
coverage and billing information. The files are available html and PDF format. Bulletins
are offered at no cost and can be found on our website under the Education Header.
Interactive Voice Response (IVR)
The Interactive Voice Response (IVR) System is available to providers 24 hours a day, 7
days a week with allowances for normal claims processing and system mainframe
availability as well as normal IVR and system maintenance. IVR instructions are located
on the Cahaba GBA website on the Contact Us tab.
10
Email-Notification Service
We encourage everyone to subscribe to our e-mail lists to receive important Medicare
updates in your e-mail box. This service is free. When you subscribe, we'll send you
periodic e-mails with the latest news and updates from Cahaba and CMS.
CMS Mailing List
CMS offers an electronic mailing list service for those interested in receiving news from
the Centers for Medicare & Medicaid Services (CMS). This service is optional. CMS
values your privacy. Your e-mail address, should you choose to subscribe, will be used
only for sending listserv messages and will not be shared with third parties. CMS uses
internal and third party data analytics tools, such as Google Analytics, to collect and
aggregate this information to create reports and analyses, which are used to help CMS
make our websites more useful to visitors. From this web site page, you can subscribe or
unsubscribe from any of CMS's mailing lists.
CMS e-News
Subscribe now to receive the weekly CMS Medicare FFS Provider e-News for the latest
Fee-For-Service program information, event announcements, claims and pricer
information, and MLN educational product updates. Provider Partners are typically
national organizations representing providers who participate in the Medicare FFS
11
program, who agree to assist CMS educate the provider community. Professional
associations who begin a Provider Partnership with CMS are automatically signed-up to
receive our weekly Medicare FFS Provider e-News newsletter.
CMS.HHS.gov Email Updates List
CMS is happy to offer a free email subscription service, which allows CMS.HHS.gov
users to receive notifications by e-mail when new information is available. With a
subscription profile, you get the updated information on the items of interest to you
automatically without having to return to the website and check for changes.
MLN Products
The Medicare Learning Network (MLN) is the home for education, information, and
resources for the Medicare Fee-For-Service provider community. The MLN gives you
access to the Medicare Program information you need, when you need it, so you can
focus more on providing care to your patients. Visit this website to receive the latest
MLN products and announcements.
Cahaba
Cahaba welcomes your comments and questions. You can reach us via e-mail, in writing
or by telephone. If you have any questions, please feel free to visit our Contact Us page
on the Cahaba website.
12