We noted four years ago that Medicare did not cover a number of clinical preventive services that family physicians often advocate for their patients (see “An Ounce of Prevention,” FPM, April 1998, page 10). At that time, the passage of federal legislation had begun to remedy the situation by liberalizing coverage for some of the clinical preventive services Medicare covers and expanding coverage to include several other services. That trend has continued. Here's the latest on what's covered and how to get paid for those services that you provide.

Screening mammography

Medicare covers an annual screening mammogram for all women over age 39 and one baseline mammogram for women between the ages of 35 and 39. CPT code 76092, “Screening mammography, bilateral (two-view film study of each breast)” is used to report this service. The Medicare deductible does not apply. The beneficiary is responsible for 20 percent of the Medicare-approved amount.

Screening Pap smears and pelvic exams

Medicare covers screening Pap smears and pelvic exams (including a clinical breast exam) with some limitations.

The law allows payment for one screening Pap smear and pelvic exam every two years, but Medicare may pay for one annually if the beneficiary falls into one of the following categories:

• Patient is of childbearing age and has had an exam indicating the presence of cervical or vaginal cancer or other abnormality during any of the preceding three years;

• Patient is considered to be at high risk for vaginal cancer as evidenced by prenatal exposure to diethylstilbestrol or for cervical cancer as evidenced by any of the following:

• Early onset of sexual activity (under 16 years of age),

• Multiple sexual partners (five or more in a lifetime),

• History of a sexually transmitted disease (including HIV),

• Absence of three negative Pap smears or complete absence of Pap smears within the previous seven years.

Submit HCPCS code G0101 for the screening pelvic exam, including breast exam. HCPCS code Q0091 describes obtaining, preparing and conveyance of the cervical or vaginal smear specimen to the laboratory. The laboratory that analyzes the specimen will report the appropriate CPT code for the pathology service. You can code G0101 or Q0091 with an evaluation and management (E/M) service, but you will need to add a -25 modifier to the E/M service to indicate that it was significant and separately identifiable. As with a screening mammogram, the beneficiary is responsible for 20 percent of the Medicare-approved amount, and the Medicare deductible does not apply.

Colorectal cancer screening

Medicare covers the following colorectal cancer screening tests:

• Annual screening fecal-occult blood tests for beneficiaries 50 years or older (use HCPCS code G0107),

• Screening flexible sigmoidoscopy every four years for beneficiaries 50 years or older (use HCPCS code G0104),

• Screening colonoscopy every two years for beneficiaries at high risk, such as those with a family history of cancer or previous cancer illness (use HCPCS code G0105), or once every 10 years (but not within four years of a screening sigmoidoscopy) for beneficiaries not at high risk (use HCPCS code G0121).

In addition, Medicare now covers a screening barium enema as a substitute for either a screening sigmoidoscopy or a screening colonoscopy under the same conditions applied to those two tests. Use HCPCS code G0106 when a screening barium enema is substituted for a screening sigmoidoscopy and G0120 when a screening barium enema is substituted for a screening colonoscopy. Reimbursement for the screening barium enema will equal reimbursement for a diagnostic barium enema.

The beneficiary is not responsible for any coinsurance or deductible on the fecal-occult blood test. However, on all of the other tests, the beneficiary is responsible for 20 percent of the Medicare-approved amount, and the patient's annual Part-B deductible does apply.

Diabetes self-management

Medicare covers diabetes self-management education and training when furnished to an individual with diabetes by a certified provider in an outpatient setting (for more information on this benefit, see “Billing Medicare for Diabetes Self-Management Training,” FPM, April 2001, page 14). To get paid for diabetes training, you will need to file a claim with Medicare using one of the following HCPCS codes:

• G0108 “Diabetes outpatient self-management training services, individual, per 30 minutes,”

• G0109 “Diabetes self-management training services, group session (2 or more), per 30 minutes.”

Medicare also covers blood-glucose monitors, test strips and lancets for all beneficiaries who have diabetes, without regard to whether they use insulin. In any case, the beneficiary is responsible for 20 percent of the Medicare-approved amount, and the services and supplies are subject to the annual Part-B deductible.

Prostate cancer screening

Medicare covers an annual prostate cancer screening test for men over age 50. Such tests include digital rectal exams (DREs) and prostate-specific antigen (PSA) blood tests. The code for DREs is G0102, and the code for PSAs is G0103. Note that billing and payment for a DRE is to be bundled into the payment for a covered E/M service when the two services are furnished to a patient on the same day. If the DRE is the only service provided or is provided as part of an otherwise noncovered service, HCPCS code G0102 would be payable separately if all other coverage requirements are met. Prostate cancer screening DREs and screening PSA blood tests must be billed using screening code V76.44 (“Special screening for malignant neoplasms, prostate”). Beneficiaries are responsible for 20 percent of the Medicare-approved amount for covered DREs, which are subject to the annual Part-B deductible; there is no coinsurance or deductible applicable to the screening PSA test.

For more information on this benefit, see the Medicare Coverage Issues Manual section 50–55 (cms.hhs.gov/manuals/06_cim/ci50.asp) and Medicare Carriers Manual section 4182 (cms.hhs.gov/manuals/14_car/3b4175.asp#_1_5c).

Vaccines

Medicare continues to cover vaccinations for influenza, pneumococcal pneumonia and hepatitis B. The flu and pneumococcal pneumonia shots are covered for everyone with Medicare, and they are not subject to Medicare coinsurance or deductible provisions as long as the physician or other health care professional accepts assignment. Hepatitis B coverage extends to Medicare beneficiaries at medium or high risk for hepatitis, and it is subject to both the coinsurance and deductible provisions. In addition to reporting the appropriate CPT code for the vaccine in question, you should report the appropriate HCPCS code for its administration: G0008 (influenza), G0009 (pneumococcal) and G0010 (hepatitis B).

Bone mass measurements

Medicare generally covers bone mass measurements once every two years for certain Medicare beneficiaries who are at risk for losing bone mass. If Medicare determines it to be medically necessary, more frequent bone mass measurements may be covered. Payment will be based on the appropriate CPT or HCPCS code submitted for the service; a list of those codes and other coverage criteria can be found in the Medicare Carriers Manual section 4181 (cms.hhs.gov/manuals/14_car/3b4175.asp#r1640a). The service is subject to Medicare's coinsurance and deductible provisions.

Glaucoma screening

As of Jan. 1, 2002, Medicare covers glaucoma screening once every 12 months for Medicare beneficiaries at high risk for glaucoma, including people with diabetes or a history of glaucoma. The screening must be done by or under the supervision of an optometrist or ophthalmologist. Glaucoma screening done by an optometrist or ophthalmologist should be coded using G0117; such screening done under supervision should be coded using G0118. The beneficiary is responsible for 20 percent of the approved amount after meeting his or her annual Part-B deductible.

For more information

Medicare has developed a pamphlet to help you inform your Medicare patients about Medicare coverage of preventive services. It includes a chart that explains which preventive services Medicare covers for whom, and what the beneficiary pays. You can find it online at www.medicare.gov/publications/pubs/pdf/prevent.pdf.