Medical Management Resources can provide your practice with the necessary information and personnel to correct any existing problems, assist in preventing further complications, and insure compliance with payer requirements while capturing all permissible reimbursement. This service will be performed in a confidential and timely fashion. We are always available to answer your questions and concerns.
The office hours are: Monday- Friday 8:30-4:30 pm
(Eastern Daylight Time)
Item 17 – Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician . All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in item 17. When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each ordering, referring, or supervising physician.
Additional instructions for form version 02/12: Enter one of the following qualifiers as appropriate to identify the role that this physician (or non-physician practitioner) is performing:
Qualifier Provider Role
DN Referring Provider
DK Ordering Provider
DQ Supervising Provider
Enter the qualifier to the left of the dotted vertical line on item 17.
NOTE: Under certain circumstances, Medicare permits a non-physician practitioner to perform these roles. Refer to Pub 100-02, Medicare Benefit Policy Manual, chapter 15 for non-physician practitioner rules. Enter non-physician practitioner information according to the rules above for physicians.
Are you ready? Have you used the GEM’s on the CMS website to begin converting and learning about your specialties new ICD-10-CM codes? Don’t delay. All the 2014 ICD-10-CM files are free on the CMS website.
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.
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.
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:
42-Certified Nurse Midwife
89-Certified Clinical Nurse Specialist
For purposes of this covered service, the following place of service (POS) codes are applicable:
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
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:
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)).
(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.
(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.
This week, Indiana opened its Medicaid Electronic Health Record (EHR) Incentive Program for registration to Medicaid eligible professionals (EPs) and eligible hospitals. EPs and eligible hospitals in this states will be able to receive Medicaid EHR incentive payments after successfully registering and attesting at the state level to having adopted, implemented, or upgraded certified EHR technology. More information about the Medicaid EHR Incentive Program can be found on the Medicare and Medicaid EHR Incentive Program Basics page of the CMS EHR website.
If you provide healthcare services to Medicaid beneficiaries in Indiana, and want more information about participating in the Medicaid EHR Incentive Program, visit Indiana’s Medicaid Agency website here:
As of May 2, 15 states have launched their Medicaid EHR Incentive Programs, and seven states have issued incentive payments to Medicaid EPs and eligible hospitals that have adopted, implemented, or upgraded certified EHR technology. CMS looks forward to announcing the launches of additional states’ programs in the coming months.
While this checklist is not mandatory and does not replace the need for underlying medical records, it can be used as a guide to improve regulatory compliance before ordering a Power Mobility Device (PMD) for Medicare patients.
The CPT code for reimbursement is G0372.
Sample Checklist for the PMD Examinations
The medical record for the patient includes the following history:
_____ Signs/Symptoms that limit ambulation;
_____ Diagnoses that are responsible for these signs/symptoms;
_____ Medications or other treatment for these signs/symptoms;
_____ Progression of ambulation difficulty over time;
_____ Other diagnoses that may relate to ambulatory problems;
_____ How far the patient can ambulate without stopping and with what assistive device, such as a cane or walker;
_____ Pace of ambulation;
_____ History of falls, including frequency, circumstances leading to falls, what ambulatory assistanc(cane, walker, wheelchair) is currently used and why it is not sufficient;
_____ What has changed in the patient’s condition that now requires the use of a power mobility device;
_____ Reason for inability to use a manual wheelchair; such as assessment of upper body strength;
_____ Why does the patient need a power wheelchair rather than each level of mobility assistive equipment (a cane, walker, optimally configured manual wheelchair, scooter)? What are the reasons that the patient should not or could not use a cane, walker, optimally configured manual wheelchair or power operated vehicle (scooter) in the home to satisfy theirneeds?; and
_____ Description of the home setting, including the ability to perform activities of daily living in the home, as well as the ability to utilize the PMD in the home.
The physical examination is relevant to the patient’s mobility needs and the medical record for the patient contains:
_____ Weight and Height
_____ Musculoskeletal examination
_____ Neurological examination
We have heard that they may still be denying the 33 modifier even though they released this information about the modifer.
Anthem’s reference to the 33 modifier
on the right hand side, click the link on the pdf article “new modifier for preventive services”.