The following article contains frequently asked questions and answers about billing Medicare for Transitional Care Management Services.

Transitional care billing answers

According to AHIMA, CMS responded to them in a February 19, 2013 letter that they intended to keep the ICD-10-CM/PCS implementation date of October 1, 2014.  http://ahima.org/downloads/pdfs/advocacy/HHS_ICD-10.pdf.  As such, training and education starting now is imperative to having a successful transition from ICD-9 to ICD-10 by that time.  Please contact us for more informtion on our ICD-10 implementation program.

Link to AMA’s 2013 PQRS for Group and Individual Measures.

https://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-quality-reporting-system-2013.page?

NCCI 2012 Transmittal

Effective October 1, 2012, CMS will implement a phased Therapy Cap  Exception (TCE) process.  The  implementation schedule is provided below.   During this period, the 2012 therapy cap amounts will be $1880 for  occupational therapy services and $1880 for the combined services for physical  therapy and speech-language pathology.  All  requests for therapy services above $3,700 which are provided by a speech  language therapist, physical therapist, or physician shall be approved or  disapproved in advance.  Settings include  Part B SNF, CORF, ORF, private practices, rehabilitation agencies, and hospital  outpatient departments.  Occupational  therapy provided above $3,700 shall also be approved in advance.

CMS has also provided a list of providers (NPIs) who will be required to  submit a request for pre-approval of a specific number of additional therapy  treatment days, not to exceed 20 per discipline, each time the patient is  expected to require more therapy then previously approved.

This Therapy Cap Exception process will be implemented in phases:

• Phase I: October 1, 2012 – December 31, 2012
• Phase II: November 1, 2012 – December 31, 2012
• Phase III: December 1, 2012 – December 31, 2012

“Medicare Therapy Cap Exception Form” will be required to be completed for preapproval requests.  The form is available on CGS home page. Click on the heading to go to that page.

• Medicare Therapy Cap Exception Form

In addition to the completed request form, the following  information and documentation must also be submitted with each request:

• Orders for the additional therapy  services;
• Licensure/certification of person who will perform therapy services or documentation of education/degree requirements are met if “qualified” but not licensed;
• Justification; [For example, information in support of the assertion that the beneficiary’s functional and/or treatment needs involving ambulation and mobility cannot be adequately met unless Physical Therapy or Occupational Therapy is provided by a licensed physical or occupational therapist or physical or occupational therapy assistant working under the supervision of a licensed       physical or occupational therapist and that these services can be reasonably expected to (1) achieve measurable and sustained functional gains for the beneficiary, or (2) establish a safe and effective maintenance program. In the case of Speech Language Pathology services, that the service recipient’s functional and/or treatment needs for communication/articulation/swallowing function, etc. require the services of a licensed Speech Language Pathologist and that these services can be reasonably expected to (1) achieve measurable and sustained functional gains for the beneficiary or (2) establish a safe and effective maintenance program];
• Evaluation or reevaluation for medical necessity and certified Plan of Care;
• Certification of the plan of  care;
• Progress reports;
• Treatment notes;
• Certification or recertification for therapy services;
• Objectives and measurable goals and any other documentation required by the relevant Local Coverage Determination (LCD). (Objectives and goals should also state an estimate of a reasonable time frame in which the recipient could be expected to achieve the stated goals.)
• A statement of the amount of  additional services needed. A provider may request up to 20 additional  treatment days of service per request

Upon completion of the review, providers will receive a decision  letter.  The decision letter will include  a TCE identification number to be used to identify your claim when filed.  To ensure proper processing  of the claim for these services, insert the  TCE identification number assigned to you in block 19 of the CMS 1500 claim form  (comments fields/reserved field).

Providers may submit their completed Therapy Cap Exception request  form via fax to:

(615) 664-5946    Therapy Cap Part A OH
(615) 664-5944    Therapy Cap Part A KY
(615) 664-5973    Therapy Cap Part B OH
(615) 664-5963    Therapy Cap Part B KY
(615) 664-5993    Therapy Cap HHH

Or by mail to:

J15 Part B Therapy CAP Requests
P.O. Box 24357
Nashville, TN  37202

J15 HH&H Therapy CAP Requests
P.O. Box 23468
Nashville, TN 37202

J15 Part A Therapy CAP Requests
P.O. Box 23558
Nashville, TN. 37202

 

In a new press release from HHS, Secretary Kathleen Sebelius announced a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013 to October 1, 2014.
The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS).
The full release can be found on the CMS Website, and more information about this proposed rule can be found on the proposed rule ICD-10 fact sheet. A segment of the HHS press release is located below.
The Department of Health and Human Services (HHS) today announced a proposed rule that would establish a unique health plan identifier (HPID). The change would save the health care industry up to $4.6 billion over ten years by enabling greater automation of electronic health care transactions, in turn helping physicians spend less time interacting with health plans — and more time with patients.
The proposed rule was developed by the Office of E-Health Standards and Services (OESS), as part of its ongoing role, delegated by HHS, to adopt standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS). The proposed rule would implement several administrative simplification provisions of the Affordable Care Act.
The proposed rule also would delay by one year, until Oct. 1, 2014, the date by which covered entities must comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10). Covered entities are defined in HIPAA as (1) health plans, (2) health care clearinghouses, and (3) health care providers who electronically transmit any health information in connection with a transaction for which HHS has adopted a standard .
Some provider groups have expressed serious concerns about their ability to meet the October 1, 2013 compliance date. CMS and HHS believe the change in the compliance date for ICD-10, as proposed in this rule, would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition among all industry segments.

News Updates | April 9, 2012

HHS Press Release: HHS Secretary Kathleen Sebelius Announces Delay of ICD-10 until October 1, 2014

In a new press release from HHS, Secretary Kathleen Sebelius announced a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013 to October 1, 2014

The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS).

The full release can be found on the CMS Website, and more information about this proposed rule can be found on the proposed rule ICD-10 fact sheet. A segment of the HHS press release is located below.

The Department of Health and Human Services (HHS) today announced a proposed rule that would establish a unique health plan identifier (HPID). The change would save the health care industry up to $4.6 billion over ten years by enabling greater automation of electronic health care transactions, in turn helping physicians spend less time interacting with health plans — and more time with patients.

The proposed rule was developed by the Office of E-Health Standards and Services (OESS), as part of its ongoing role, delegated by HHS, to adopt standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS). The proposed rule would implement several administrative simplification provisions of the Affordable Care Act.

The proposed rule also would delay by one year, until Oct. 1, 2014, the date by which covered entities must comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10). Covered entities are defined in HIPAA as (1) health plans, (2) health care clearinghouses, and (3) health care providers who electronically transmit any health information in connection with a transaction for which HHS has adopted a standard .

Some provider groups have expressed serious concerns about their ability to meet the October 1, 2013 compliance date. CMS and HHS believe the change in the compliance date for ICD-10, as proposed in this rule, would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition among all industry segments.

Keep Up to Date on Version 5010 and ICD-10.
Please visit the ICD-10 website for the latest news and resources to help you prepare, and to download and share the implementation widget today!

We are receiving many calls and e-mails concerning denials on 95885 and 95886 (CPT codes are the copyright of the AMA). Please check your state Part B Local Coverage determinations. Medical necessity must be shown on the claim for these codes. Your denial is not due to any modifiers that we can see from the CCI edits.

95900 and 95904 are codes that 95885 and 95886 can be added onto but all line items must have medical necessity.

If you have grown tired of providing your services free of charge after hours, this post is for you.

I spoke today with Dr. Sidney VanNess, President and CEO of Lexington, KY based On Call Central.  Dr. VanNess’ company has developed a technology that replaces the standard answering service.  On Call Central maintains permanent MP3 recordings of phone calls between patients and providers. You can view a demonstration of the technology in action by clicking on the video on their website.

The upshot of having recordings is that it is easier to successfully bill for the existing CPT codes for telephone evaluation and management consultations (99441, 99442, 99443). According to Dr. VanNess, several private insurers, as well as Medicaid in some states (Indiana included), are reimbursing for calls. Below is a screenshot taken yesterday from the Indiana Medicaid fee schedule, as well as a redacted remittance advice Dr. VanNess provided from a practice that successfully billed $125 for a 11-20 minute phone call.

Though the amounts may not be huge, they are certainly more than most practices currently receive.

Dr.VanNess conducts a free one on one webinar entitled “Billing for Phone Calls” that provides an overview of what is necessary to turn your after hours patient interactions into a revenue generating activity.

More information about this technology can found on the website listed.

G0442 ANNUAL ALCOHOL MISUSE SCREENING, 15 MINUTES

G0443 BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE, 15 MINUTES

G0444 ANNUAL DEPRESSION SCREENING, 15 MINUTES

G0445 HIGH INTENSITY BEHAVIORAL COUNSELING TO PREVENT SEXUALLY TRANSMITTED INFECTION; FACE-TO-FACE,INDIVIDUAL, INCLUDES: EDUCATION, SKILLS TRAINING AND GUIDANCE ON HOW TO CHANGE SEXUAL BEHAVIOR; PERFORMED SEMI-ANNUALLY, 30 MINUTES

G0446 INTENSIVE BEHAVIORAL THERAPY TO REDUCE CARDIOVASCULAR DISEASE RISK, INDIVIDUAL, FACE-TO-FACE, BI-ANNUAL, 15 MINUTES

G0447 FACE-TO-FACE BEHAVIORAL COUNSELING FOR OBESITY, 15 MINUTES

No diagnosis instructions have been released by CMS as of this printed document 1/12/2012.

Effective October 14, 2011, Medicare will add new codes G0442, G0443, G0444 with a mid-quarter National Coverage Determination (NCD) approval date of 10/14/11. Edit 68 is affected.

Effective November 8, 2011, Medicare will add new codes G0445 and G0446 with a mid-quarter NCD approval date of 11/8/11. Edit 68 is affected.

G0442, G0443

Pursuant to Section1861(ddd) of the Social Security Act, CMS may add coverage of “additional preventive services” through the National Coverage Determination (NCD) process if all of the following criteria are met. They must be: (1) reasonable and necessary for the prevention or early detection of illness or disability, (2) recommendedwith a grade of A or B by the United States Preventive Services Task Force (USPSTF), and, (3) appropriate for individuals entitled to benefits under PartA or enrolled under Part B of the Medicare Program. CMS reviewed the USPSTF’s “B” recommendation and supporting evidence for “Screening and Behavioral Counseling Intervention in Primary Care to Reduce Alcohol Misuse” preventive services and determined that all three criteria were met.

According to the USPSTF (2004), alcohol misuse includes risky/hazardous and harmful drinking which place individuals at risk for future problems; and in the general adult population, risky or hazardous drinking is defined as >7 drinks per week or >3 drinks per occasion for women, and >14 drinks per week or >4 drinks per occasion for men. Harmful drinking describes those persons currently experiencing physical, social or psychological harm from alcohol use, but who do not meet criteria for dependence.

Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women:

who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms,
impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and, who are competent and alert at the time that counseling is provided; and, whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a
primary care setting.

Each of the four behavioral counseling interventions must be consistent with the 5As approach that has been adopted by the USPSTF to describe such services:

Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the
skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

NOTE: Two new G codes, G0442 (Annual Alcohol Misuse Screening, 15 minutes), and G0443 (Brief face-to-face behavioral counseling for Alcohol Misuse, 15 minutes), are effective October 14, 2011, and will appear in the January quarterly update of the Medicare Physician Fee Schedule Database (MPFSDB) and Integrated Outpatient Code Editor (IOCE). For claims with Dates of Service on or after October 14, 2011, through December 31, 2011, your Medicare contractor will use their pricing to pay for G0442 and/or G0443. Deductible and coinsurance do not apply. Contractors will hold institutional claims received prior to April 2, 2102, with TOBs 13X, 71X, 77X, and 85X and release those claims beginning April 2, 2012.

For the purposes of this covered service, the following provider specialty types may submit claims for G0442 and G0443:

01-General Practice

08-Family Practice

11-Internal Medicine

16-Obstetrics/Gynecology

37-Pediatric Medicine

38-Geriatric Medicine

42-Certified Nurse Midwife

50-Nurse Practitioner

89-Certified Clinical Nurse Specialist

97-Physician Assistant

For purposes of this covered service, the following place of service (POS) codes are applicable:

11-Physician’s Office

22-Outpatient Hospital

49-Independent Clinic

71-State or local public health clinic

Rural Health Clinics (RHCs) using type of bill (TOB) 71X and Federally Qualified Health Centers (FQHCs) using TOB 77X may submit additional revenue lines containing G0442 or G0443. Medicare will pay G0442 and G0443 in TOBs 71X and 77X based on the all-inclusive payment rate. However, Medicare will not pay G0442 or G0443 separately with another encounter/visit on the same day billed on TOBs 71X or 77X. This does not applyto claims for the Initial Preventive Physical Examination (IPPE), claims containing modifier 59, or to 77X claims containing Diabetes Self-Management Training or Medical Nutrition Therapy services. If G0442 or G0443 is billed when an encounter/visit with the same line item date of service, Medicare will assign:

Group Code CO to the G0442/G0443 revenue lines; and

RARC 97: “The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.” Note: Refer to the 835 Healthcare Policy
Identification Segment (loop 2110 Service Payment Information REF), if present.

Institutional claims billed by hospital outpatient departments (TOB 13X) will be paid based on the Outpatient Prospective Payment System. Those billed by Critical Access Hospitals (CAHs) on TOB 85X will be paid based on reasonable cost, except those G0442 or G0443 services billed with revenue codes 096X, 097X, or 098X by Method II CAHs willreceive 115% of the lesser of the fee schedule amount or submitted charge. Institutional claims submitted on TOBs other than 13X, 71X, 77X, or 85X will bedenied using the following:

CARC 5: “The procedure code/bitt type is inconsistent with the place of service.” Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC M77: “Missing/incomplete/invalid place of service.”

Group Code CO.

Medicare will allow payment for both G0442 and G0443 on the same date (except in RHCs and FQHCs), but will not pay for more than one G0443 service on the same date. However, Medicare will allow
both a claim for the professional service and, for TOB 13X and TOB 85X without a revenue code of 96X, 97X, or 98X, a claim for a facility fee. Claim lines for G0443 that exceed the limit of one on the same date of service will be denied using:

CARC 151: “Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.”

RARC M86: “Service denied because payment already made for same/similar procedure within set time frame.”

Group Code CO.

Medicare will track payments for G0442 screening services and G0443 counseling services so as to not permit paymentfor G0442 more than once in a 12-month period, and for G0443 no more than 4
times in a 12-month period, beginning with the date of the G0442 service. Claim lines exceeding these limits will be denied using:

CARC 119: “Benefit maximum for this time period or occurrence has been reached.”

RARC N362: “The number of days or units exceeds our acceptable maximum.”

Group Code CO.
As of July 2, 2012, provider inquiry screens (HUQA, HIQA, HIQH, ELGA, ELGB, ELGH) along with HICR changes.

G0444 Effective October 14, 2011, Medicare covers annual screening for adults for depression in the primary care settingthat has staff-assisted depression care supports in place to assure accurate
diagnosis, effective treatment, and follow-up.  Medicare contractors will recognize new Healthcare Common Procedure Coding System (HCPCS) code, G0444, annual depression screening, 15 minutes, as a covered service.

NOTE: This code will appear on the January 2012 Medicare Physicians Fee Schedule update. The Type of Service (TOS) for HCPCS code G0444 is 1. Effective October 14, 2011, beneficiary coinsurance and deductibles do not apply to claim lines with annual depression screening, G0444. For Dates of Service on or after October 14, 2011, through December 31, 2011, Medicare contractors will use their pricing for paying G0444 and update their HCPCS files accordingly  Among persons older than 65 years, one in six suffers from depression. Depression in older adults is estimated to occur in 25% of those with other illness including cancer, arthritis, stroke, chronic lung disease, and cardiovascular disease. Other stressful events, such as the loss of friends and loved ones, are also risk factors for depression. Opportunities are missed to improve health outcomes when mental illness is under-recognized and under-treated in primary care settings.

Older adults have the highest risk of suicide of all age groups. These patients are important in the primary care setting because 50-75% of older adults who commit suicide saw their medical doctor during the prior month for general medical care, and 39% were seen during the week prior to their death. Symptoms of major depression that are felt nearly every day include, but are not limited to, feeling sad or empty; less interest in daily activities; weight loss or gain when not dieting; less ability to think or concentrate; tearfulness, feelings of worthlessness, and thoughts of death or suicide.

Section1861(ddd) of the Social SecurityAct permits the Centers for Medicare & Medicaid Services (CMS) to addcoverage of “additional preventive services” through the National Coverage Determination (NCD) process if all of the following criteria are met:

Reasonable and necessary for the prevention or early detection of illness or disability;

Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF); and,
Appropriate for individuals entitled to benefits under Part A or enrolled under Part B.

Screening for depression in adults is recommended with a grade of B by the USPSTF. The CMS reviewed the USPSTF recommendations and supporting evidence for screening depression in adults
preventive services and determined that the criteria listed above was met, enabling the CMS to cover these preventive services.

Thus, effective October 14, 2011, Medicare covers annual screening for adults for depression in a primary care setting, as defined below, that has staff-assisted depression care supports in
place to assure accurate diagnosis, effective treatment, and follow-up. For the purposes of this NCD:

A primary care setting is defined as one in which there is provision of integrated, accessible health care services byclinicians who are accountable for addressing a large majority of personal
health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospice are not considered primary care settings under this definition.

Effective for claims with Dates of Service on and after April 2, 2012, contractors shall pay for annual depression screening claims, G0444, only when services are provided at the following
Places of Service (POS):

11 – Office

22 – Outpatient hospital

49 – Independent clinic

50 – FQHCs

71 – State or local public health clinic

72 – RHCs

At a minimum level, staff-assisted depression care supports consist of clinical staff (e.g., nurse, Physician Assistant) in the primary care office who can advise the physician of screening
results and who can facilitate and  supports include a case manager working with the primary care physician; planned collaborative care between the primary care provider and mental health
clinicians; patient education and support for patient self-management; plus attention to patient preferences regarding counseling, medications, and referral to mental health professionals with or without continuing involvement by the patient’s primary care physician.

Note: Coverage is limited to screening services and does not include treatment options for depression or any diseases, complications, or chronic conditions resulting from depression, nor does it
address therapeutic interventions such as pharmacotherapy, combination therapy (counseling and medications), or other interventions for depression. Self-help materials, telephone calls, and web-based counseling are not separately reimbursable by Medicare and are not part of this NCD.

Screening for depression is non-covered when performed more than one time in a 12-month period. Eleven full months must elapse following the month in which the last annual depression screening took
place. Medicare coinsurance and Part B deductible are waived for this preventive service.

G0445 Effective for claims with dates of service  on and after November 8, 2011, CMS will cover screening for chlamydia,gonorrhea, syphilis, and hepatitis B with the appropriate FDA approved/cleared
laboratory tests, used consistent with FDA approved labeling and in compliancewith the Clinical Laboratory Improvement Act (CLIA) regulations, when ordered by the primary care provider, and performed by an eligible Medicare provider for these services. Also effective for claims with Dates of Service on and after November 8, 2011, CMS will cover up to two individual – 20 to 30 minute,
face to face counseling sessions annually for Medicare beneficiaries for High Intensity Behavioral Counseling (HIBC) to prevent Sexually Transmitted Infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs, if referred for this service by a primary care provider and provided by a Medicare eligible primary care provider in a primary care setting. For the purposes of this NCD, a primary care setting is defined as the provision of integrated, accessible health care services by clinicians who areaccountable for addressing a large majority of personal health care needs,
developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings,ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, clinics providing a limited focus of health care services, and hospice are examples of settings not considered primary care settings under this definition.

Therefore, CMS will cover screening for these USPSTF indicated STIs with the appropriate FDA approved/clearedlaboratory tests, used consistent with FDA approved labeling and in compliance
with the Clinical Laboratory Improvement Act (CLIA) regulations, when ordered by the primary care physician or practitioner, and performed by an eligible Medicare provider for these services.

Screening for chlamydia and gonorrhea:

Pregnant women who are 24 years old or younger when the diagnosis of pregnancy is known and then repeat screening during the third trimester if high risk sexual behavior has occurred since the
initial screening test.

Pregnant women who are at increased risk for STIs when the diagnosis of pregnancy is known and then repeat screening during the third trimester if high risk sexual behavior has occurred since the
initial screening test.

Women at increased risk for STIs annually.

Screening for syphilis:

Pregnant women when the diagnosis of pregnancy is known and then repeat screening during the third trimester and at delivery if high risk sexual behavior has occurred since the previous screening
test.

Men and women at increased risk for STIs annually.

Screening for hepatitis B:

Pregnant women at the first prenatal visit when the diagnosis of pregnancy is known and then rescreening at time of delivery for those with new or continuing risk factors.

CMS will also cover up to two individual 20 to 30 minute, face to face counseling sessions annually for Medicare beneficiaries for HIBC to prevent STIs for all sexually active adolescents and
for adults at increased risk for STIs, if referred for this service by a primary care provider and provided by a Medicare eligible primary care provider in a primary care setting. Coverage of HIBC to prevent STIs is consistent with the USPSTF recommendation. HIBC is defined as a program intended to promote sexual risk reduction or risk avoidance which includes each of these broad topics, allowing flexibility for appropriate patient-focused elements:

education,

skills training,

guidance on how to change sexual behavior.

The high/increased risk individual sexual behaviors, based on the USPSTF guidelines, include any of the following:

Multiple sex partners

Using barrier protection inconsistently

Having sex under the influence of alcohol or drugs

Having sex in exchange for money or drugs

Age (24 years of age or younger and sexually active for women for chlamydia and gonorrhea)

Having an STI within the past year

IV drug use (for hepatitis B only)

In addition for men – men having sex with men (MSM) and engaged in high risk sexual behavior, but no regard to age

In addition to individual risk factors, in concurrence with the USPSTF recommendations, community social factors such as high prevalence of STIs in the community populations should be considered in
determining high/increased risk for chlamydia, gonorrhea, syphilis and for recommending HIBC.

High/increased risk sexual behavior for STIs is determined by the primary care provider by assessing the patient’ssexual history which is part of any complete medical history, typically part of
an annual wellness visit or prenatal visit and considered in the development of a comprehensive prevention plan. The medical record should be a reflection of the service provided.

For the purposes of this decision memorandum, a primary care setting is defined as the provision of integrated, accessible health care services by clinicians who are accountable for
addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, clinics providing a limited focus of health care services, and hospice are examples of settings not considered primary care settings under this definition.

For the purposes of this decision memorandum, a “primary care physician” and “primary care practitioner” will be defined consistent with existing sections of the Social Security Act (§1833(u)(6), §1833(x)(2)(A)(i)(I) and §1833(x)(2)(A)(i)(II)).

§1833(u)

(6) Physician Defined.—For purposes of this paragraph, the term “physician” means a physician described in section 1861(r)(1) and the term “primary care physician” means a physician who is identified in the available data as a general practitioner, family practice practitioner, general internist, or obstetrician or gynecologist.

§1833(x)(2)(A)(i)

(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or

(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in section 1861(aa)(5));

G0446 Effective  for claims with dates of service on and after November 8, 2011, CMS will cover intensive behavioral therapy for cardiovascular disease (referred to below as a CVD risk reduction visit), which consists of the following three components: 1) encouraging aspirin use for the primary prevention of cardiovascular diseasewhen the benefits outweigh the risks for men age 45-79 years and women 55-79 years; 2) screening for high blood pressure in adults age 18 years and older; and 3) intensive behavioral counseling to promote a healthy diet for adultswith hyperlipidemia, hypertension, advancing age, and other known risk factors for cardiovascular and diet-related chronic disease. Effective for claims withdates of service on and after November 8, 2011, CMS covers one face-to-face CVD
risk reduction per year for Medicare beneficiaries who are competent and alert at the time that counseling is provided, and whose counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. For the purposes of this NCD , a primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices are not considered primary care settings under this definition.

To implement this recent coverage determination, CMS created a new G-code to report the CVD risk reduction visit.

G0447 Effective for claims with dates ofservice on and after November 29, 2011, Medicare beneficiaries with obesity(BMI ≥ 30 kg/m2), who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary care setting are eligible for: 1) One face to face visit every week for the first month; 2) One face to face visit every other week for months 2-6; and 3) One face to face visit every month for months 7-12.