University
Physicians
Audit and
Reimbursement Department
February 20, 2002
MEDICARE COVERED SCREENING SERVICES
March is Colorectal Cancer Awareness Month. Important Facts You Should
Know about Colorectal Cancer! (From a Program Memorandum published by
Part B News)
· Colorectal cancer is the second leading cause of cancer related
deaths for men and women in the United States.
· More than one-third of colorectal cancer deaths could be avoided
if people over 50 had regular screening test.
· Most colorectal cancers begin with polyps. (Polyps are growths
on the inner wall of the colon or rectum)
· Colorectal cancer starts with no symptoms. (When colorectal
cancer is detected in the earliest stage of the disease - Stage 1- the
survival rate is 96 percent.)
· Risk increases as we age.
· Both men and women are at risk.
· African-Americans are more likely than whites to be diagnosed
with colorectal cancer at a more advanced stage and more likely to die
of it once diagnosed.
· Medicare helps pay for colorectal cancer screening test.
Fecal Occult Blood Test: (done at home) is covered one per year. You
pay no coinsurance and no Part B deductible. (G0107)
Flexible Sigmoidoscopy : Covered once every 4 years. Effective for claims
with dates of service on or after 1/1/2002, coverage criteria for Screening
Flex Sig was changed to add physician assistants, nurse practitioners
and clinical nurse specialist to the list of providers (doctor of medicine
or osteopathy) that can perform screening flex sig. (G0104).
Colonoscopy
High Risk Individuals - If you are at high risk for colorectal cancer,
Medicare covers a colonoscopy or a barium enema every 2 years.
( G0105)
Average Risk Individuals - Beginning July 1, 2001, if you are at average
risk for colorectal cancer, Medicare will cover a colonoscopy every
10 years. However, if you are at average risk and have had a covered
flexible sigmoidoscopy, you must wait 4 years to be eligible for Medicare
coverage of a colonoscopy. (G0121)
Barium Enema - This test can substitute for a flexible sigmoidoscopy
or for a colonoscopy. (G0106, G0120 or G0122)
Other Medicare covered screenings services ---
In recent years Congress has added several import screening services
to Medicare's benefit package. Many of these are payable due to a BIPA
law passed in 2000.
· Bone Density Screening - Medicare will pay once every two
(2) years for patients at risk of losing bone mass. Note: Medicare will
pay for more than one screening every two (2) years in certain clinically
justified situations. Our carrier will make a case-by-case decision
on these additional screenings. ( G0130-G0132; 76075-76078, 76977, 78350)
· Diabetes self-management training: Billable when provided
to patients who are at risk for complications from diabetes. However,
comprehensive self-management training can be billed only if you're
part of an accredited program. Minor training or counseling can be billed
as part of an E/M code. (G0108, G0109)
· Glaucoma Screening: Medicare will reimburse once a year for
patients with diabetes or family history of glaucoma and for African
Americans over the age of 50. Payment will NOT be made if screening
is performed as part of a Medicare-covered eye exam. (G0117, G0118)
· Screening Mammograms: Once a year for female patients over
the age of 40. Patients age 35-39 with Medicare coverage are allowed
one "baseline" mammogram before the 40th birthday. Additional
payment for screening that utilizes digital technology. (76092, G0202,
76085)
· Pap Test and Pelvic Exam: Coverage once every 12 months for
high risk for cervical or vaginal cancer, or if childbearing age and
had an abnormal pap test in the past 36 months. For all other patient
coverage once every 24 months. (G0101)
· Prostate Cancer Screening: Once every 12 months for both a
digital rectal and PSA for male patients age 50 and over. (G0102, G0103)
· Vaccinations: Flu shots, once each flu season, Administration
code G0008
Pneumococcal pneumonia, once during a lifetime, Administration code
G0009
Hepatitis B for patient at medium to high risk for hepatitis B.
Administration code G0010
Brenda Diehls, CPC Senior Management Analyst UP - Audit
and Reimbusementr
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