American College of Physicians: Internal Medicine — Doctors for Adults ®

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Medicare expands several of its screening policies

From the July 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

Q: How has Medicare expanded its screening colonoscopy benefit?

A: As of July 1, Medicare began covering screening colonoscopies every 10 years for beneficiaries not considered high risk for colorectal cancer, as long as they have not undergone a screening flexible sigmoidoscopy within the past 48 months. Last year, Congress expanded Medicare's coverage of screening colonoscopies beyond beneficiaries considered high risk for colorectal cancer. Medicare's coverage remains unchanged for screening colonoscopies for beneficiaries who are considered high risk for the disease.

Medicare defines high risk as individuals who have a family history of colorectal cancer; prior experience with cancer or precursor neoplastic polyps; a history of chronic digestive disease conditions (including inflammatory bowel disease, Crohn’s disease or ulcerative colitis); the presence of any appropriate recognized gene markers for colorectal cancer; or other predisposing factors. Medicare covers a screening colonoscopy for high-risk beneficiaries every two years.

To bill for a screening colonoscopy for a beneficiary who is not considered high risk for colorectal cancer, use HCFA Common Procedure Coding System (HCPCS) code G0121. The code applies to colorectal cancer screening on individuals who do not meet the criteria for high risk.

The Medicare 2001 payment for a screening colonoscopy performed in a hospital or other facility on a patient who is not high risk for colorectal cancer (G0121) is $239.51. (This rate will vary slightly by geographic area.) Medicare gives the same payment for a screening colonoscopy on a high-risk beneficiary, G0105, and a diagnostic colonoscopy, CPT 45378.

Q: What other screening benefits has Medicare changed?

A: The 2000 law increased the frequency by which Medicare covers screening Pap smears and pelvic exams, which include clinical breast exams. Medicare will now pay for screening Pap smears and pelvic exams every two years for women who are postmenopausal and/or not at high risk for cervical or vaginal cancer. Before July 1, Medicare covered the use of these services for screening purposes every three years.

Medicare continues to cover an annual screening Pap smear and pelvic exam for women of childbearing age who have had an abnormal Pap smear within three years or are considered at high risk for cervical or vaginal cancer. Medicare considers a woman at high risk if she has a prior history of cancer or sexually transmitted disease; began having sexual intercourse before age 16; has had more than five sexual partners; has not had a Pap smear within seven years; or has a mother who used diethylstilbestrol during pregnancy.

Screening Pap smear. Use HCPCS code Q0091 to report the process of obtaining, preparing and conveying the specimen to the laboratory. Medicare pays $38.26 for this code when the specimen is obtained in your office or other outpatient setting. (This rate will vary slightly by geographic area.)

Medicare will pay you separately for obtaining a specimen for a screening Pap smear during a patient office visit or other evaluation and management (E/M) service. You must append CPT modifier –25 to the E/M service to indicate that it is a significant, separately identifiable service performed on the same date as a specimen collection service. For example, if a beneficiary visits your office for ongoing treatment of her chronic hypertension—a service consistent with a mid-level established patient office visit, CPT 99213—and you obtain a specimen for a screening Pap smear, bill 99213-25 in addition to HCPCS Q0091.

Screening pelvic and clinical breast exam. Use HCPCS G0101 to report a pelvic exam. The Medicare 2001 payment rate for G0101 is $39.41. (This rate will vary slightly by geographic area.)

Medicare will pay separately for a screening pelvic and clinical breast exam, G0101, and for obtaining a specimen for a Pap smear, Q0091, when the two services are billed together for the same patient on the same date. Accordingly, Medicare will pay for both G0101 and Q0091 when they are billed with an E/M service, as long as the E/M service is appended with modifier –25.

Medicare will pay separately for a pelvic and clinical breast exam performed during a medically necessary office visit even if you do not obtain a specimen for a screening Pap smear. Append the E/M service with modifier –25 and also bill G0101 for the pelvic and clinical breast exam.

Brett Baker is a third-party payment specialist in the College’s Washington Office. If you have questions about third-party payment or coding issues, contact him at 202-261-4533 or bbaker@acponline.org.

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