Event/Question and Answer Summary
Gail O’Leary welcomed 95 participants to the call. Attendees were informed that this call is intended for providers in Jurisdiction 6 & K, which consists of the states of Illinois, Minnesota, Wisconsin, Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont. The purpose of the call was discussed and the question and answer portion of the call was explained. Participants were informed of the different members of the National Government Services staff who were on the call to assist with questions.
Nathan Kennedy discussed the following:
- Nathan explained this Ask-the-Contractor teleconference was to answer questions providers did not have the chance to have answered during our three-day Medicare Preventive Services virtual conference. He reviewed the topics presented over the past two days.
- We will be holding our semi-annual virtual conference on 11/9-10/2021. We will be offering multiple sessions for Part A, B and some sessions that cover both lines of business.
- Nathan shared information about CMS' MLN® Educational Tool: Medicare Preventive Services that covers all of the covered preventive and screening services Medicare offers. He also showed the audience NGS' Preventive Services web pages.
- James Bavoso spoke about CMS’ focus on preventive medicine and the underutilization of them.
The question box was opened and attendees were invited to ask their questions.
Question and Answer Summary
- Is it correct to report CPT 99401 if it is exclusively for counseling our unvaccinated population on the COVID-19 vaccines? (Assuming properly documented as well).
Answer: Medicare does not cover counseling and education for vaccinations – when the vaccine is being provided, the administration fee includes this in the reimbursement. Also, 99401 is Status N on the MPFSDB which means it is a noncovered service for Medicare.
- Did I understand correctly the AWV can be performed with a family member, patient not present?
Answer: During the webinar covering the AWV, advance care planning was also discussed as a component to the AWV. This component can be performed with a family member, however, the AWV cannot. The patient needs to be present.
- How will a claim be treated if a product is a category 3 code?
Answer: Category 3 codes do not fall into the preventive services realm. Category 3 codes are processed like any other code.
- Can preventive services be reported as incident-to?
Answer: Incident-to services are their own benefit category. There could be some preventive services that will allow a physician to supervise auxiliary staff, but you would have to look at the specific service to find out if incident-to would be allowed.
- As long as the provider documents the reason, is it sufficient to be able to count any required AWV element unable to be performed (i.e. inability to measure height/weight for a bedridden nursing home patient)?
Answer: Some elements such as height and weight can be substituted, however not all parameters of it can be substituted. As for the health assessment the patient needs to complete, the doctor should at least document that they tried to get all of the information from the patient.
- Can you please tell me if there are differences in billable services between the AWV and the subsequent AWV? Example: is the depression screening separately billable on both?
Answer: If it is listed as part of a specific item of the AWV, then no, it is not separately billable. If it is not part of the AWV, then it could be billed separately. You may refer to the CMS MLN® Educational Tool: Medicare Wellness Visits to find all components of the AWV.
- How many preventive services can be billed on the same date of service?
Answer: You would have to look at the specific service to find out if they can be billed together. For instance, the Diabetes Self-Management Training and Medical Nutrition Therapy services cannot be billed on the same day to the same patient, however, some services do not have a set policy on whether it can be performed on the same day. Medical necessity must also be taken into consideration.
- Can an E/M visit be billed in addition to an AWV when the patient has no complaints and nothing abnormal noted in the review of systems or exam, but provider orders labs for a chronic condition? Or if refilling a prescription would that count to bill a separate E/M?
Answer: An E/M can be billed separately if you can identify medical necessity requirements for the service. They would have to be two completely separately identifiable services in order to be billed separately, and not a component of the AWV.
- Please explain carve-out when well woman exam billing with 99397, G0101, Q0091 - did I understand correctly CMS does not mandate carve-outs?
Answer: CMS does not mandate carve-outs – this has to do with the charge, what you charge the patient as far as for the preventive if it is not covered. What you should do is take the amount paid by Medicare, subtract that from the physician’s usual fee for the preventive service, and the remaining balance would be the patient’s responsibility. That is what is referred to as a carve-out.
- Is depression screening billable when performed at a FQHC?
Answer: This is a Part B call – however, G0444 is payable in an FQHC, TOB 77X, however it is not payable as another encounter or visit. For more information, we recommend you call the PCC. You can reach them at: JK: 888-855-4356 or J6: 877-702-0990.
- Many of these preventive visits have time, for instance 15 minutes. These webinars have indicated as per the CPT guidelines that if 8-15 minutes are spent we can bill the code, for instance depression screening. How do I verify that CMS is applying this rule to all codes that say 15 minutes or if the rule does not apply?
Answer: From a general coding standpoint, CMS follows CPT guidelines unless CMS has published something different indicating they are doing it differently in a specific situation. This information can be found in CMS' IOM or in NCD policy language and/or within the Social Security Act itself.
- Can you talk about E/M and vaccines – billing them together?
Answer: If the patient is coming in just for the vaccination, you cannot bill for a separate E/M service. You would only bill for the vaccine (if it was not provided for free) and its administration. However, if you have a separately identifiable E/M service performed at the same time as the patient received a vaccination, this is coverable. The medical documentation would have to be clear on how it is a completely separate service over and above the vaccination service.
There used to be a MLN paper reference of all the screening services, versus this new electronic method. Is there anything still like that as that was easy to print off for providers?
Answer: No, CMS offers the MLN® Educational Tool: Medicare Preventive Services interactive chart. You can print each service – they offer a print button for the service you are interested in.
The frequency of Hepatitis C screening has been changed to once for all patients aged 18-79 per USPSTF guidelines. Prior to this, the recommendation was to check once in patients born 1945-1965. Do you know if/when the CMS coverage policy will be updated to reflect this?
Answer: No, we do not know when or if CMS intends to update this policy. The medical directors at CMS look at not just the USPSTF> guidelines, they look at several sources of information and make a determination on policy and coverage guidelines.
Can the office nurse ask the patient family social history, medication and supplement and home safety questions for the provider during the Initial Preventive Physical Exam and the provider reviews it? Or is this strictly only for the provider to do?
Answer: Those questions can be asked via a questionnaire type document, however they do have to be reviewed and gone over with the patient by the physician or practitioner performing the service.
Please clarify whether time must be documented to bill for depression screenings performed with subsequent AWVs.
Answer: Yes, any code that has a time constraint needs to have the time documented in some format, and in that situation, if you’re doing a service separate from another service, you have to have the time indicated for each service. There needs to be a break indicating this time was for service A and this time was for service B. You cannot lump all of the times together, there needs to be a clear indication of how much time was spent for each service.
If a patient has a positive fecal immunochemical test and then goes on to have a colonoscopy, is the colonoscopy still considered screening?
Answer: Per our Carrier Medical Director, it is diagnostic. An abnormality was detected on a screening test.
Can a patient be billed for a telephone nurse encounter?
Answer: The patient cannot be charged for anything that is a noncovered service or for something that does not meet the Medicare benefit criteria. If the nurse is calling with test results or something of that nature, you cannot charge the patient for that telephone call. In the case of a mental health emergency, a nurse is not a billing practitioner so if the nurse is talking to the patient in a mental health emergency, we would expect there would be a service to follow that, but there is no billable service if a nurse performs it.
Is surveillance colonoscopy considered high-risk and if so when will the screening diagnosis be accepted as primary? The NCD has personal history but not the screening code. The new ICD-10-CM guidelines state the screening code must be reported first.
Answer: Surveillance colonoscopy is a procedure. High-risk is a diagnosis dependent upon the patient’s history. Surveillance colonoscopy is a screening service that is allowed once every 24 months if the patient is at high risk. In regard to ICD-10 guidelines those would be followed unless there is specific policy published stating otherwise. However, as mentioned, this is not a screening procedure.
I believe that there is a "Coding Clinic" article that addresses that question of the home fecal testing prior to a colonoscopy. It states that if there is a positive fecal testing, the colonoscopy then becomes diagnostic. So, whether CMS follows that Coding Clinic guideline would be the question.
Answer: CMS follows CMS and/or MAC published policy for procedures. The “Coding Clinic”, published by the American Hospital Association, is a publication that addresses coding parameters and is not a CMS policy document.
If a colonoscopy begins as a screening, but a polyp is found, removed and sent to pathology does the pathologist assign a screening code as primary or would this be considered diagnostic for the pathology charges (not GI billing)?
Answer: If the procedure starts as a screening and a polyp is found, it becomes diagnostic. The procedure code would reflect a diagnostic colonoscopy with polyp and removal. The biopsy would also be diagnostic as well, as the polyp needs to be diagnosed as to what it is.
Do you cover Truvada counseling for HIV prevention?
Answer: No, this is not separately billable as counseling and education for immunizations is included in the administration fee.
Would diagnosis code Z13.1, encounter for screening for diabetes be covered for a hemoglobin A1C?
Answer: Providers need to choose one of the procedure codes for screening for diabetes, 82947, 82950 and 82951 and they would use the Z13.1 for the diagnosis code. If the patient was diagnosed with pre-diabetes they can have two of those screening tests within a 12-month period, but at least six months need to have passed following the first test, and the modifier TS should be appended to the second test. A1C is not an acceptable diagnosis for the test.
The call was closed. We thanked the attendees for their participation and informed the group that the next Ask-the-Contractor call would be held in December, 2021 and that the event summary would be posted to our website within 30 business days.