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MIR-20007-1AB, January 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Implementation of a One-Time Only Ultrasound Screening for Abdominal Aortic Aneurysms (AAA), Resulting from a Referral from an Initial Preventive Physical Examination
| Note: This article was changed on December 8, 2006 to add emphasize that this coverage is for a one-time only service and it must also be as a result of a referral from an initial preventive physical exam and is also subject to other limitations as discussed in this article and in CR5235. |
Provider Types Affected
All physicians and providers who bill Medicare carriers, fiscal intermediaries (FIs), and Medicare Administrative Contractors (MACs) for subject services
Background
This article and related CR5235 highlight the fact that section 5112 of the Deficit Reduction Act (DRA) of 2005 allows for one ultrasound screening for Abdominal Aortic Aneurysms (AAA) under Medicare Part B, effective for services furnished on or after January 1, 2007, as a result of a referral from an Initial Preventive Physical Examination (IPPE) and subject to certain eligibility and other limitations. This provision also waives the annual Part B deductible for the AAA screening test.
Key Points
Effective for dates of service on and after January 1, 2007, Medicare will pay for a one-time ultrasound screening for AAA, for beneficiaries who meet the following criteria:
Receives a referral for such an ultrasound screening as a result of an initial preventive physical examination (IPPE). (See MLN Matters article MM3638 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3638.pdf  for more details on the IPPE.)
- Receives such ultrasound screening from a provider or supplier who is authorized to provide covered ultrasound diagnostic services.
- Has not been previously furnished such an ultrasound screening under the Medicare Program.
- Is included in at least one of the following risk categories:
- Has a family history of abdominal aortic aneurysm;
- Is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime;
- Is a beneficiary, who manifests other risk factors in a beneficiary category recommended for screening by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and Human Services, through the national coverage determinations process.
Payment
- The Part B deductible for screening AAA is waived effective January 1, 2007, but coinsurance is applicable.
- If the screening is provided in a physician office, the service is billed to the carrier using the HCPCS code G0389: Ultrasound, B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening.
- Short Descriptor: Ultrasound exam AAA screen
- Modifiers: TC, 26 (modifiers are optional)
- Payment is under the Medicare Physician Fee Schedule (MPFS)
FIs will pay for the AAA screening only when the services are performed in a hospital, including a CAH, IHS facility, an SNF, RHC, or FQHC and submitted on one of the following types of bills (TOBs): 12X, 13X, 22X, 23X, 71X, 73X, 85X.
- The following table describes the payment methodology Medicare will use for AAA Screening:
Facility |
Type of Bill |
Payment |
Hospitals subject to OPPS |
12X, 13X |
OPPS |
Method I and Method II Critical Access Hospitals (CAHs) |
12X and 85X |
101 percent of reasonable cost |
IHS providers |
13X, revenue code 051X |
OMB-approved outpatient per visit all inclusive rate (AIR) |
IHS providers |
12X, revenue code 024X |
All-inclusive inpatient ancillary per diem rate |
IHS CAHs |
85X, revenue code 051X |
101 percent of the all-inclusive facility specific per visit rate |
IHS CAHs |
12X, revenue code 024X |
101 percent of the all-inclusive facility specific per diem rate |
SNFs ** |
22X, 23X |
Non-facility rate on the MPFS |
RHCs* |
71X, revenue code 052X |
All-inclusive encounter rate |
FQHCs* |
73X, revenue code 052X |
All-inclusive encounter rate |
Maryland Hospitals under jurisdiction of the Health Services Cost Review Commission (HSCRC) |
12X, 13X |
94 percent of provider submitted charges or according to the terms of the Maryland Waiver |
* If the screening is provided in an RHC or FQHC, the professional portion of the service is billed to the FI using TOBs 71X and 73X, respectively, and the appropriate site of service revenue code in the 052X revenue code series. If the screening is provided in an independent RHC or freestanding FQHC, the technical component of the service can be billed by the practitioner to the carrier under the practitioner’s ID following instructions for submitting practitioner claims to the Medicare carrier. If the screening is provided in a provider-based RHC/FQHC, the technical component of the service can be billed by the base provider to the FI under the base provider’s ID, following instructions for submitting claims to the FI from the base provider.
** The SNF consolidated billing provision allows separate part B payment for screening services for beneficiaries that are in skilled Part A SNF stays, however, the SNF must submit these services on a 22X bill type. Screening services provided by other provider types must be reimbursed by the SNF. |
Implementation
The implementation date for this instruction is January 2, 2007.
Information Regarding Advanced Beneficiary Notices: Medicare contractors will deny an AAA screening service billed more than one in a beneficiary’s lifetime.
If a second G0389 is billed for AAA for the same beneficiary or if any of the other statutory criteria for coverage listed in Section 1861(s)(2)(AA) of the Social Security Act are not met, the service would be denied as a statutory (technical) denial under Section 1861(s)(2)(AA), not a medical necessity denial.
If a provider cannot determine whether or not the beneficiary has previously had an AAA screening, but all of the other statutory requirements for coverage have been met, the provider should issue the ABN-G. Likewise, if all of the statutory requirements for coverage have been met, but a question of medical necessity still exists, the provider should issue the ABN-G.
Additional Information
The official instructions for CR 5235, issued to your Medicare carrier, FI, MAC, FQHC, RHC, SNF, or CAH regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1113CP.pdfn the CMS Web site. The Medicare Claims Processing Manual, Publication 100-04, Chapter 18, has been updated to include the requirements to implement section 5112 of the DRA of 2005. The new sections of this chapter address the payment and allowable settings for AAA and the sections are attached to CR5235.
If you have questions, please contact your Medicare carrier, MAC, or FI at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5235 Revised
Pub. 100-4, Transmittal #: R1113CP , CR# 5235
Related CR Release Date: November 17, 2006
Effective Date: January 1, 2007
Implementation Date: January 2, 2007
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