CMS Manual System

CMS Manual System

Pub 100-04 Medicare Claims Processing

Transmittal 3232

Department of Health & Human Services (DHHS)

Centers for Medicare & Medicaid Services (CMS)

Date: April 3, 2015 Change Request 8874

Transmittal 3160, dated January 7, 2015, is being rescinded and replaced by Transmittal 3232 to remove the references to coinsurance and deductible from BR 8874.10.1, add the PT modifier and the inapplicability of the deductible to BR 8874.10.1.1, expand the range of surgical services to which the PT modifier applies in BR 8874.10.1.1, add CWF responsibility to BR 8874.10.1.1, and to add the PT modifier to BR 8874.10.1.2. The Medicare Claims Processing Manual, Chapter 18, section 1.2, Table of Preventive and Screening Services, is changed to add a sentence to the NOTE concerning billing with the PT modifier before code G0104 and Chapter 18, section 60.1.1, is changed to add a sentence concerning billing with the PT modifier. All other information remains the same.

SUBJECT: Preventive and Screening Services -- Update - Intensive Behavioral Therapy for Obesity, Screening Digital Tomosynthesis Mammography, and Anesthesia Associated with Screening Colonoscopy

I. SUMMARY OF CHANGES: The purpose of this change request (CR) is to ensure accurate program payment for three screening services for which the beneficiary should not be charged the coinsurance or deductible. The coinsurance and deductible for these services are currently waived, but due to coding changes and additions to the Medicare Physician Fee Schedule Database, the payments for CY 2015 would not be accurate without this CR for intensive behavioral group therapy for obesity, digital breast tomosynthesis, and anesthesia associated with colorectal cancer screening tests.

EFFECTIVE DATE: January 1, 2015 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 5, 2015

Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW, D=DELETED

R/N/D R R R N N

CHAPTER / SECTION / SUBSECTION / TITLE 18/Table of Contents 18/1.2/Table of Preventive and Screening Services 18/20.2/HCPCS and Diagnosis for Mammography Services 18/20.2.2/Screening Digital Tomosynthesis 18/20.2.3/Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages

R/N/D R R R R R R

R

CHAPTER / SECTION / SUBSECTION / TITLE 18/60.1/Payment 18/60.1.1/Deductible and Coinsurance 18/200.1/Policy 18/200.2/Institutional Billing Requirements 18/200.3/Professional Billing Requirements 18/200.4/Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages 18/200.5/Common Working File (CWF) Edits

III. FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

IV. ATTACHMENTS:

Business Requirements Manual Instruction

Attachment - Business Requirements

Pub. 100-04 Transmittal: 3232

Date: April 3, 2015

Change Request: 8874

Transmittal 3160, dated January 7, 2015, is being rescinded and replaced by Transmittal 3232 to remove the references to coinsurance and deductible from BR 8874.10.1, add the PT modifier and the inapplicability of the deductible to BR 8874.10.1.1, expand the range of surgical services to which the PT modifier applies in BR 8874.10.1.1, add CWF responsibility to BR 8874.10.1.1, and to add the PT modifier to BR 8874.10.1.2. The Medicare Claims Processing Manual, Chapter 18, section 1.2, Table of Preventive and Screening Services, is changed to add a sentence to the NOTE concerning billing with the PT modifier before code G0104 and Chapter 18, section 60.1.1, is changed to add a sentence concerning billing with the PT modifier. All other information remains the same.

SUBJECT: Preventive and Screening Services - Update - Intensive Behavioral Therapy for Obesity, Screening Digital Tomosynthesis Mammography, and Anesthesia Associated with Screening Colonoscopy

EFFECTIVE DATE: January 1, 2015 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 5, 2015

I. GENERAL INFORMATION

A. Background: Intensive Behavioral Therapy for Obesity

Intensive behavioral therapy for obesity became a covered preventive service under Medicare, effective November 29, 2011. It is reported with HCPCS code G0447 (Face-to-face behavioral counseling for obesity, 15 minutes). Coverage requirements are delineated in the Medicare National Coverage Determinations Manual, Pub. 100-03, chapter 1, section 210.

To improve payment accuracy, in the CY 2015 PFS Proposed Rule, CMS is creating a new HCPCS code for the reporting and payment of behavioral group counseling for obesity and in the CY 2015 PFS Final Rule with comment period, CMS finalized this proposal and added HCPCS code G0473 (Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes) to the Medicare Physician Fee Schedule Database. For coverage requirements of these services, see the National Coverage Determination for Intensive Behavioral Therapy for Obesity.

Screening Digital Breast Tomosynthesis

Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening mammographies for women over age 40 and waives the Part B deductible. Screening mammography has been assigned a "B" rating from the United States Preventive Services Task Force (USPSTF) for women every 1 to 2 years for those 40 years and older. Due to the Affordable Care Act amendments to section 1833(a)(1) of the Act, the coinsurance for mammography services is waived as well.

In the CY 2015 PFS Final Rule with comment period, CMS is establishing a payment rate for the newly created CPT code 77063 for screening digital breast mammography. The same policies that are applicable to other mammography should be applicable to CPT code 77063. In addition, since this is an add-on code it should only be paid when furnished in conjunction with a 2D digital mammography. Accordingly, Medicare will only pay for this code when furnished with G0202.

Anesthesia furnished in conjunction with Colonoscopy

Section 4104 of the Affordable Care Act defined the term "preventive services" to include "colorectal cancer screening tests" and as a result it waives any coinsurance that would otherwise apply under section 1833(a)(1) of the Act for screening colonoscopies. In addition, the Affordable Care Act amended section 1833(b)(1) of the Act to waive the Part B deductible for screening colonoscopies. These provisions are effective for services furnished on or after January 1, 2011.

In the CY 2015 PFS Proposed Rule, CMS proposed to revise the definition of "colorectal cancer screening tests" to include anesthesia separately furnished in conjunction with screening colonoscopies and in the CY 2015 PFS Final Rule with comment period, CMS finalized this proposal. The definition of "colorectal cancer screening tests" includes anesthesia separately furnished in conjunction with screening colonoscopies in the Medicare regulations at ?410.37(a)(1)(iii). As a result, beneficiary coinsurance and deductible does not apply to anesthesia services associated with screening colonoscopies.

B. Policy: Intensive Behavioral Therapy for Obesity

Effective for claims with dates of service January 1, 2015 and after, the practitioner furnishing intensive behavioral therapy for obesity in a group setting shall report the relevant group code for each beneficiary participating in a group therapy session. The qualified practitioner furnishing these services shall report HCPCS code G0473 when furnishing these services to a maximum group of ten beneficiaries.

Coinsurance and Deductible

Effective January 1, 2015, beneficiary coinsurance and deductible does not apply to claim lines with the following HCPCS code G0473: Face-to-face behavioral counseling for obesity, group (2-10), 30 minute(s)

Screening Digital Breast Tomosynthesis

Effective January 1, 2015, HCPCS code 77063 (Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure)), must be billed in conjunction with the screening mammography HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views, 2 D imaging only.

Coinsurance and Deductible

Effective January 1, 2015, beneficiary coinsurance and deductible does not apply to claim lines with the following HCPCS codes:

? 77063: Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)

Anesthesia furnished in conjunction with Colonoscopy Effective January 1, 2015, anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy shall include the following on the claim for the services that qualify for the waiver of coinsurance and deductible:

? Modifier 33 ? Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used. In the event that a screening colonoscopy becomes a diagnostic colonoscopy, the HCPCS 00810 anesthesia claim should be submitted with modifier PT-

colorectal cancer screening test; converted to diagnostic test or other procedure. This will trigger the claims processing system to not apply the deductible to the service, but co-insurance will still apply. Modifier 33 and modifier PT should not be submitted on the same claim line for HCPCS 00810.

Coinsurance and Deductible

Effective January 1, 2015, beneficiary coinsurance and deductible does not apply to the following anesthesia claim lines when furnished in conjunction with screening colonoscopy services and when billed with Modifier 33:

? 00810: Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum

NOTE: New codes will be effective January 1, 2015, and will appear in the January 2015 updates of the Medicare Physician Fee Schedule Database (MPFSDB) and the Integrated Outpatient Code Editor (IOCE).

II. BUSINESS REQUIREMENTS TABLE

"Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.

Number 8874.1

Requirement

Effective for claims with dates of service on or after January 1, 2015, contractors shall recognize HCPCS codes G0473, Face-to-Face Behavioral Counseling for Obesity, group (2-10), 30 minute(s).

Responsibility

A/B D Shared-

Other

MAC M System

E Maintainers

A B H F MV C H M I C MW HAS S S F C S

X X

X

X IOCE

8874.2

Contractors shall allow payment of HCPCS code G0473 only when billed with one of the ICD-9 codes for BMI 30.0 and over (V85.30-V85.39, V85.41-V85.45).

X X

XX X

NOTE: Contractors shall note that the appropriate ICD- 10 code(s) are listed below. Contractors shall track the ICD-10 code/edits (and add the code(s)/edit(s) to their system when applicable) and ensure that the updated edit is functional as part of the ICD-10 implementation. NOTE: You will not receive a separate Change Request instructing you to implement updated edits. BMI 30.0 and over ? Z68.30-Z68.39, Z68.41- Z68.45.

8874.2.1

Effective for claims with dates of service on or after January 1, 2015, contractors shall deny claims lines for HCPCS code G0473 that are not submitted with one of the diagnosis codes listed in 8874.2.

X X

X X

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