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, subject to certain eligibility and other limitations. This provision also waives the annual Part B deductible for the AAA screening test.

Key Points
This article and CR 5235 define the parameters for AAA to Medicare beneficiaries as follows:

• The term “ultrasound screening for abdominal aortic aneurysm” means:
• A procedure using sound waves (or such other procedures using alternative technologies, of commensurate accuracy and cost, as specified by the Secretary of Health and Human Services through the national coverage determination process) provided for the early detection of abdominal aortic aneurysms; and
• Includes a physician’s interpretation of the results of the procedure.
• 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 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:
• 1. Has a family history of abdominal aortic aneurysm;
• 2. Is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime;
• 3. 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:

Matters Number: MM5235 Related Change Request Number: 5235
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 once 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.pdf on 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.

Flu Shot Reminder
Flu season is here! Medicare patients give many reasons for not getting their flu shot, including --“It causes the flu; I don’t need it; it has side effects; it’s not effective; I didn’t think about it; I don’t like needles!” The fact is that out of the average 36,000 people in the U.S. who die each year from influenza and complications of the virus, greater than 90 percent of deaths occur in persons 65 years of age and older. You can help your Medicare patients overcome these odds and their personal barriers through patient education. Talk to your Medicare patients about the importance of getting their annual flu shot--and don’t forget to immunize yourself and your staff.

Protect yourself, your patients, and your family and friends. Get Your Flu Shot.
Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.

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
Pub. 100-4, Transmittal# R1113CP , CR#5235
Related CR Release Date: November 17, 2006
Effective Date: January 2, 2007
Implementation Date: January 1, 2007

Do you have your NPI?
National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

Posted: 11/27/2006

CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.