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


Changes in Medicare coverage that will affect internists

Medicare has established coverage for some screening tests and boosted pay for vaccine administration

From the April ACP Observer, copyright 2005 by the American College of Physicians.

By Brett Baker

On Jan. 1, 2005, the Centers for Medicare and Medicaid Services (CMS) began implementing several changes that are affecting internists' ability to deliver preventive care to Medicare beneficiaries. Most of those changes were mandated by the Medicare Prescription Drug Modernization and Improvement Act of 2003.

For one, the CMS launched the new "Welcome to Medicare" exam, an initial preventive exam that Medicare now covers for all patients enrolled in Medicare Part B. (For more information, see "How to bill for the new 'Welcome to Medicare' exam" in the Jan.-Feb. ACP Observer. More information about acceptable screening tools needed to furnish the "Welcome to Medicare" exam is also available. (The CMS also has improved payments for physicians who work in underserved areas. See "Boosting payments in underserved areas.")

But the new Medicare legislation also authorized covering screening tests for Medicare patients. The following is an overview of those changes.

Cardiovascular screening blood tests

Q: Does Medicare cover blood tests to screen for cardiovascular disease?

A: Beginning Jan. 1, 2005, Medicare began paying for cardiovascular screening blood tests for the early detection of cardiovascular disease and abnormalities associated with an elevated risk of heart disease and stroke. Under this new benefit, Medicare now covers the following tests:

  • total cholesterol test;
  • cholesterol test for high density lipoproteins; and
  • triglycerides.

Q: How often does Medicare cover these screening tests?

A: For the purpose of cardiovascular screening, Medicare covers them once every five years. The CMS rejected ACP's request for more frequent coverage, stating that cholesterol and lipid levels remain fairly consistent in the elderly population.

Q: What codes should I use to order or bill for these tests?

A: Use the following three Current Procedural Terminology (CPT) codes to receive payment for these services:

  • 82465: cholesterol, serum or whole blood, total;
  • 83718: lipoprotein, direct measurement and high-density cholesterol; and
  • 84478: triglycerides.

If you're ordering all three, use the CPT lipid panel code (80061). (CPT created lab panel codes to make it easier for physicians to report groups of tests that are commonly ordered together.) Use the individual codes if you order or perform less than three tests.

The CMS requires you to select from the following diagnosis codes to indicate that you ordered or performed the test(s) for screening purposes:

  • V81.0: special screening for ischemic heart disease;
  • V81.1: special screening for hypertension; and
  • V81.2: special screening for other and unspecified cardiovascular conditions.

Note that Medicare will deny a claim for a lipid panel and/or individual tests if it has paid a claim supported by a screening diagnosis code within the past 60 months.

Q: What does Medicare pay labs to perform these screening tests?

A: Medicare pays the same rate for these tests whether you bill for screening or diagnostic tests. As with other Medicare-covered lab tests, neither the beneficiary deductible nor the co-payment applies.

Diabetes screening tests

Q: Does Medicare now pay for diabetes screening tests?

A: Starting Jan. 1, 2005, Medicare began covering screening tests for beneficiaries who are at risk for diabetes or who have been diagnosed with pre-diabetes. Covered tests include fasting blood glucose test and post-glucose challenge tests, which are not limited to the following:

  • an oral glucose tolerance test with a glucose challenge of 75 grams for nonpregnant adults; or
  • a two-hour post glucose challenge test alone.

Note that Medicare does not cover these tests to screen beneficiaries who already have been diagnosed with diabetes.

Medicare considers patients to be at risk for diabetes if they have any one of the following risk factors:

  • hypertension;
  • dyslipidemia;
  • obesity (with a body mass index greater than or equal to 30 kg/m2); or
  • previous identification of elevated impaired fasting glucose or glucose intolerance.

Medicare also considers beneficiaries to be at risk for diabetes if they have any two of the following risk factors:

  • a body mass index greater than 25 but less than 30kg/m2;
  • a family history of diabetes;
  • they are age 65 years or older; or
  • a history of gestational diabetes mellitus or giving birth to a baby weighing more than nine pounds.

Finally, Medicare defines pre-diabetes as a condition of abnormal glucose metabolism—including impaired fasting glucose and impaired glucose tolerance—that meets the following criteria:

  • a fasting glucose level of 100-125 mg/dL; or
  • a two-hour post-glucose challenge of 140-199 mg/dL.

Q: How often does Medicare cover these screening tests?

A: Medicare covers two screening tests per calendar year for individuals diagnosed with pre-diabetes. It covers one screening test per year for individuals previously tested who were not diagnosed with pre-diabetes or who have never been tested.

Q: What codes should I use to order or bill for these screening tests?

A: Select from the following CPT codes to report the tests listed above:

  • 82947: glucose; quantitative, blood (except reagent strip);
  • 82950: glucose; post glucose dose (includes glucose); or
  • 82951: glucose; tolerance test (GTT), three specimens (includes glucose).

One other note: When you order or perform a second test in a calendar year for a pre-diabetic patient, use a "TS" modifier to indicate that you are providing the above screening tests as a follow-up service.

To indicate that you ordered/performed the test to screen for diabetes, use the diagnosis code: V77.1: special screening for diabetes mellitus.

Q: What does Medicare pay for these covered tests?

A: Medicare pays the same rate for these tests whether you bill for screening or diagnostic tests. As with other Medicare-covered laboratory tests, neither the beneficiary deductible nor co-payment applies.

Payment for vaccine administration

Q: Has Medicare increased its payment for administering a vaccine?

A: While compensation for this service varies by geographic region, the national average payment more than doubled from $8.34 in 2004 to $18.57 in 2005. The increase pertains uniformly to the service of administering a Medicare-covered "preventive" vaccine—influenza, pneumococcal and Hepatitis B—along with "medically necessary" vaccines to treat illness or injury.

The CMS agreed to the increase after ACP and others successfully argued that physicians often play a role in vaccine administration.

To report this reimbursement, use the following CMS-maintained codes:

  • G0008: administration of influenza virus vaccine (when no physician fee schedule service occurs on the same day);
  • G0009: administration of pneumococcal vaccine (when no physician fee schedule service occurs on the same day).
  • G0010: administration of hepatitis B vaccine (when no physician fee schedule service occurs on the same day).

Use CPT 90471 to report the administration of a vaccine product that is medically necessary.

Information about Medicare's 2005 payment rate for administering the influenza vaccine is online. (The 2004 rates also are online.

Medicare's payment for vaccine administration against pneumonia, hepatitis B and other conditions is the same as compensation for administering the influenza virus vaccine.

More information on immunizations is available at the ACP Adult Immunization Initiative Web site.

Brett Baker is the Director of Regulatory and Insurer Affairs in the College's Washington Office.


Boosting payments in underserved areas

Q: Has Medicare improved payments for services furnished to beneficiaries in underserved areas?

A: Yes. The Medicare Prescription Drug Modernization and Improvement Act of 2003 established a new bonus payment to physicians who provide Medicare services in areas with a low physician-to-beneficiary ratio. (These areas are known as physician scarcity areas.) The new Medicare legislation also made it easier for physicians to collect the already existing bonus for services furnished in Health Professional Shortage Areas.

Q: What is the physician scarcity area bonus?

A: Between Jan. 1, 2005 and Dec. 31, 2007, Medicare automatically will pay a 5% scarcity bonus to physicians for services furnished in counties that account for 20% of Medicare beneficiaries. Congress established the 5% bonus payment to make it easier to recruit and retain primary care and specialist physicians.

The law instructs the CMS to calculate a scarcity ratio-based on the number of active physicians per Medicare beneficiary-for primary care and specialist physicians. Using this figure, Medicare will identify the counties in which physicians will receive a bonus payment.

This bonus applies to professional services performed by physicians, from evaluation and management services to procedures. It does not apply to the technical component of physicians' services, such as a payment for furnishing the equipment needed to run a diagnostic test.

The amount Medicare actually pays you for the service, not the Medicare allowable (which includes the beneficiary co-payment), determines the bonus amount. If your zip code places you in a physician scarcity area, you automatically will receive a 5% bonus for the Medicare services you provide on a quarterly basis.

Note that if you work in a zip code that crosses over into a county that the CMS has not defined as a physician scarcity area, you will not automatically receive the bonus. You must use the "AR" modifier to indicate that you are eligible for the 5% bonus. Instructions to determine whether you're eligible for the program—and information on whether Medicare can automatically give you the bonus payment—are online.

Q: Will Medicare now automatically pay the 10% Health Professional Shortage Areas (HPSA) bonus?

A: Yes and no. Beginning Jan. 1, 2005, Medicare, as required by the new Medicare legislation, automatically now makes the 10% bonus payment to physicians for services furnished in an HPSA (which can be rural or urban). Previously, physicians had to append a modifier to the code billed for each service furnished in these areas. But, despite the change to the law requiring automatic payment, the CMS cannot make payment for eligible services provided in some zip codes that cut into an ineligible, non-HPSA area. You must append the appropriate modifier—QB for rural HPSA or QU for urban HPSA—for an eligible service when automation is not possible.

CMS provides instructions for determining eligibility, including whether Medicare can automatically make the bonus payment, online.

Q: Is it possible to receive both the 5% scarcity area bonus and the 10% bonus for practicing in a health professional shortage area?

A: Yes. You are entitled to receive both incentive payments for services furnished in a physician scarcity area that Medicare also defines as an HPSA.

Q: What should I do if I have trouble collecting either a physician scarcity area or HPSA bonus to which I am entitled?

A: Contact your Medicare carrier if you are not receiving bonus payments despite being eligible. You can find a toll-free number for your carrier online.


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