MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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MMA-Cardiovascular Screening Blood
Tests
Provider Types Affected
Physicians, providers, and suppliers
Provider Action Needed
The
information in this article provides guidance for the new
national coverage policy related to cardiovascular
screening tests covered, effective for services performed
on or after January 1, 2005.
Background
In accordance with
Section 612 of the Medicare Modernization Act (MMA),
Medicare coverage is provided for cardiovascular
screening blood tests (tests for the early detection of
cardiovascular disease or abnormalities associated with
an elevated risk for that disease) effective for services
performed on or after January 1, 2005.
The MMA permits coverage of tests for cholesterol and
other lipid or triglycerides levels for this purpose.
Therefore, effective January 1, 2005, coverage is
provided for the following:
- Total Cholesterol Test;
- Cholesterol Test for High Density Lipoproteins;
and
- Triglycerides Test.
Effective, January 1, 2005, Medicare provides coverage
for the cardiovascular screening blood test for
beneficiaries every five years (i.e., 59 months after the
last covered screening tests.) Medicare has determined
that it is not necessary to test more frequently since
lipid and cholesterol levels for people often stay fairly
consistent beyond age 65.
Medicare Part B covers cardiovascular screening blood
tests when ordered by the physician who is treating the
beneficiary for the purpose of early detection of
cardiovascular disease in individuals without apparent
signs or symptoms.
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The implementation of this new benefit permits
Medicare beneficiaries who have not been
previously diagnosed with cardiovascular disease
to receive cardiovascular screening blood tests
for risk factors associated with cardiovascular
disease. This includes individuals who have no
prior knowledge of heart problems but recognize
that their behavior or lifestyle may be at risk
because of diet or lack of exercise.
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Payment is provided under the Medicare Clinical
Laboratory Fee Schedule. There is no deductible or
copayment for this benefit.
HCPCS/CPT Codes/Diagnosis
Codes
The following HCPCS/CPT Codes
are to be billed for the Cardiovascular Screening Blood
Tests:
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80061
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Lipid Panel
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82465
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Cholesterol, serum, or whole blood, total
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83718
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Lipoprotein, direct measurement; high-density
cholesterol
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84478
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Triglycerides
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(The tests should be performed as a panel; however,
they are also available as individual tests.)
The following diagnosis codes must be submitted on the
claim for when billing for cardiovascular screening blood
test:
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V 81.0
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Special Screening for ischemic heart disease
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V81.1
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Special Screening for hypertension
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V81.2
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Special Screening for other and unspecified
cardiovascular conditions
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Medicare will pay for cardiovascular disease screening
under the Medicare Clinical Laboratory Fee Schedule.
Providers and suppliers that bill for the cardiovascular
disease screening benefit must point the screening
diagnosis (V81.0, V81.1, V81.2) to the line item
service.
Other cardiovascular screening blood tests (for which
CMS has not specifically indicated approval for national
coverage) continue to be noncovered.
How Carriers and Intermediaries Will Treat
Claims
Medicare carriers and
intermediaries will treat claims as follows:
- Carriers/intermediaries will accept claims with
HCPCS 80061 (Lipid Panel), 82465 (Cholesterol, serum or
whole blood, total), 83718 (Lipoprotein, direct
measurement; high density cholesterol, HDL
Cholesterol), or 84478 (Triglycerides) when there is a
reported diagnosis of V81.0 (Special screening for
ischemic heart disease), V81.1 (Special screening for
hypertension), or V81.2 (Special screening for other
and unspecified cardiovascular conditions).
- Carriers/intermediaries will deny claims with code
80061 when there is already evidence of a paid claim
within the prior 60 months that was billed with a
diagnosis code of V81.0, V81.1, or V81.2, and with a
procedure code of 80061, 82465, 83718, or 84478.
- Carriers/intermediaries will deny claims with
procedure codes of 82465, 83718, or 84478 when billed
within 60 months of a previous paid claim with a
diagnosis code of V81.0, V81.1, 0r V81.2 and a
procedure code of 80061.
Additional Information
The
Medicare Claims Processing Manual, Chapter 18, Section
100 is new. The new manual instructions are attached to
the official instruction (CR3411) released to your
carrier/intermediary. You may view that instruction by
going to: http://www.cms.hhs.gov/Transmittals/downloads/R408CP.pdf
If you have any questions, please contact your
intermediary at their toll-free number, which may be
found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf
Disclaimer
Medlearn Matters articles are
prepared as a service to the public and are not intended
to grant rights or impose obligations. Medlearn Matters
articles 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.
For additional information, visit the Medlearn Matters
Web page at www.cms.hhs.gov/medlearn/matters/.
Related Change Request (CR) #:
3411
Medlearn Matters Number: MM3411
Related CR Release Date: December 17,
2004
Related CR Transmittal #: 408
Effective Date: January 1,
2005
Implementation Date: January 3, 2005
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