MIR-2007-3AB, March 2007

Reminder – Medicare Provides Coverage of Prostate Cancer Screening for Eligible Medicare Beneficiaries (SE0709)

Provider Types Affected
All Medicare fee-for-service (FFS) physicians, providers, suppliers, and other health care professionals, who furnish or provide referrals for and/or file claims for Medicare-covered prostate cancer screening services

Provider Action Needed
This article conveys no new policy that requires provider action. The article is for informational purposes only and serves as a reminder that Medicare provides coverage of certain prostate cancer screening tests subject to certain coverage, frequency, and payment limitations.

Introduction
Effective for services furnished on or after January 1, 2000, Medicare Part B covers annual preventive prostate cancer screening tests/procedures for the early detection of prostate cancer. The information in this Special Edition MLN Matters article reminds health care professionals about the coverage criteria, eligibility requirements, frequency parameters, and correct coding when billing for prostate cancer screening services so that you can talk with your Medicare patients about this preventive benefit and file claims properly for the screening service.

The Screening Services Defined

A. Screening Digital Rectal Examination (DRE)
Medicare defines a screening DRE as a clinical examination of an individual’s prostate for nodules or other abnormalities of the prostate. This screening must be performed by a doctor of medicine or osteopathy, physician assistant, nurse practitioner, clinical nurse specialist, or by a certified nurse midwife who is authorized under state law to perform the examination, fully knowledgeable about the beneficiary’s medical condition, and would be responsible for explaining the results of the examination to the beneficiary.

B. Screening Prostate Specific Antigen (PSA) Tests
Medicare defines a screening PSA as a test that measures the level of prostate specific antigen in an individual’s blood. This screening must be ordered by the beneficiary’s physician (doctor of medicine or osteopathy) or by the beneficiary’s physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife who is fully knowledgeable about the beneficiary’s medical condition, and would be responsible for explaining the results of the test to the beneficiary.

Coverage Information

Medicare Provides Coverage of the Following Prostate Cancer Screening Tests:

• Screening digital rectal examination (DRE), and
• Screening prostate specific antigen (PSA) blood test.

Eligibility and Frequency
Medicare provides coverage of an annual preventive prostate cancer screening PSA test and DRE once every 12 months for all male beneficiaries age 50 and older (coverage begins the day after the beneficiary’s fiftieth birthday), if at least 11 months have passed following the month in which the last Medicare-covered screening DRE or PSA test was performed for the early detection of prostate cancer.

Calculating Frequency
When calculating frequency, to determine the 11-month period, the count starts beginning with the month after the month in which a previous test/procedure was performed.

EXAMPLE : The beneficiary received a screening PSA test in January 2006. The count starts beginning February 2006. The beneficiary is eligible to receive another screening PSA test in January 2007 (the month after 11 months have passed).

Deductible and Coinsurance/Copayment

• The screening PSA blood test – is a lab test for which neither the deductible nor coinsurance/copayment apply.
• The screening DRE – the Medicare Part B deductible and coinsurance/copayment apply.

Claim Filing Information
The following Healthcare Common Procedure Coding System (HCPCS) codes and diagnosis code must be reported when filing claims for prostate cancer screening services:

Payment for Prostate Cancer Screening Services

• Screening PSA tests (G0103) – are paid under the clinical diagnostic laboratory fee schedule.
• Screening DREs (G0102) – are paid under the Medicare Physician Fee Schedule (MPFS) except for the following bill types identified (FI only). Bill types not identified are paid under the MPFS.
  • 12X, 13X, and 14X* = Outpatient Prospective Payment System
  • 71X and 73X = Included in All Inclusive Rate
  • 85X = Cost (Payment should be consistent with amounts paid for code 84153 or code 86316.)

* Effective 4/1/06 the type of bill 14X is for nonpatient laboratory specimens.

Additional Notes:

• Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) should include the charges on the claims for future inclusion in encounter rate calculations.
• Billing and payment for a DRE (G0102) is bundled into the payment for a covered evaluation and management service (CPT codes 99201 – 99456 and 99499) when the two services are furnished to a patient on the same day. If the DRE is the only service or is provided as part of an otherwise noncovered service, HCPCS code G0102 would be payable separately if all other coverage requirements are met.

Additional Information
For more information about Medicare’s Prostate Cancer screening benefit, visit the CMS Prostate Screening Web page: http://www.cms.hhs.gov/ProstateCancerScreening/ on the CMS Web site.

CMS has also developed a variety of educational products and resources to help health care professionals and their staff, become familiar with coverage, coding, billing, and reimbursement for all preventive services covered by Medicare.

• The MLN Preventive Services Educational Products Web Page ~ provides descriptions and ordering information for all provider specific educational products related to preventive services. The Web page is located at http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp on the CMS Web site.
• The CMS Web site provides information for each preventive service covered by Medicare. Visit http://www.cms.hhs.gov , select “Medicare,” and scroll down to “Prevention.”

For products to share with your Medicare patients, visit http://www.medicare.gov/ on the Web.

Medicare beneficiaries can obtain information about Medicare preventive benefits at http://www.medicare.gov/ and then click on “Preventive Services.” They can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

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: SE0709
Related Change Request (CR) #: N/A
Effective Date: N/A

PQRI Information Available
A new CMS Web page dedicated to providing information on the Physician Quality Reporting Initiative (PQRI) is now available.

On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative. For more information, visit http://www.cms.hhs.gov/pqri on the CMS Web site.