The Centers for Disease Control and Prevention (CDC) recognizes that “Focusing on preventing disease and illness before they occur will create healthier homes, workplaces, schools and communities so that people can live long and productive lives and reduce their health care costs.” Accordingly, the American Academy of Family Physicians (AAFP) recently asked the Centers for Medicare & Medicaid Services (CMS) to set minimum coverage standards for health prevention services and require all insurance plans to cover those services that receive an “A” or “B” recommendation from the U.S. Preventive Services Task Force (USPSTF). Medical coding outsourcing can help physicians maximize reimbursement by reporting USPSTF-recommended preventive screenings and services correctly.
Here are some examples that the AAFP gives of the USPSTF’s “A” and “B” category recommendations and the relevant codes for these preventive services.
Task Force “A” category examples:
- Colorectal Cancer screening for patients age 50-75 years: Medicare covers colorectal cancer screening test/procedures for the early detection of colorectal cancer. This coverage is subject to certain coverage, frequency, and payment limitations. Medicare waives the coinsurance and annual Medicare Part B deductible for colorectal cancer screening tests. The ICD- 10 for colorectal cancer screening is:Z12.11 Encounter for screening for malignant neoplasm of colonThe relevant HCPCS/CPT codes to use are as follows:
- 00810 – Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
- 81528 – Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result. (This code replaced G0464, effective 01/01/16)
- 82270 – Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection)
- G0104 – Flexible Sigmoidoscopy
- G0105 – Colonoscopy (high risk)
- G0106 – Barium Enema (alternative to G0104) coinsurance applies; deductible waived.
- G0120 – Barium Enema (alternative to G0105) coinsurance applies; deductible waived.
- G0121 – Colonoscopy (not high risk)
- G0328 – Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous
- G0464 – Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)
Points to note:
- Modifier -PT (colorectal cancer screening test converted to diagnostic test or other procedure) should be appended to at least one CPT code in the surgical range of 10000 to 69999 on a claim furnished on the same date and same encounter as Colonoscopy, Flexible Sigmoidoscopy, or Barium Enema that were initiated as part of colorectal cancer screening services.
- Beneficiary coinsurance and deductible do not apply to anesthesia services associated with screening colonoscopies.
- Modifier -33 should be appended to the anesthesia CPT code 00810 a separately payable anesthesia service is provided in conjunction with a screening colonoscopy (G0105 and G0121) to waive beneficiary copayment/coinsurance and deductible.
- Modifiers 33 and PT should not be submitted on the same claim line for HCPCS 00810.
- Screening pregnant women for asymptomatic bacteriuria: This involves screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks’ gestation or at the first prenatal visit, if later. The relevant codes for this service are:
- CPT code: 81007 Urinalysis, bacteriuria screen, by non-culture, commercial kit
- Pregnancy Diagnosis Code: The ICD-10 codes used should indicate the trimester of pregnancy in and an additional code from category Z3A should be used to define specific weeks of gestation
Task Force “B” Category examples
- Diabetes screening for adults age 40-70 years who are overweight or obese When filing claims to Medicare for diabetes screening tests, the following diagnosis codes and HCPCS/CPT codes must be used to ensure proper reimbursement. ICD 10 codeZ13.1 Encounter for screening for diabetes mellitus Obesity (a body mass index equal to or greater than 30 kg/m2) or Overweight (a body mass index greater than 25, but less than 30 kg/m2) are risk factors for diabetes.
Obesity intensive behavioral therapy (IBT) ICD-10 screening codes are in the range from: Z68.30 Body mass index (BMI) 30.0–30.9, adult to Z68.45 BMI 70 or greater, adult. Diabetes Screening HCPCS/CPT CodesThese codes cover Medicare beneficiaries with certain risk factors for diabetes or diagnosed with pre-diabetes:
- 82947 – Glucose; quantitative, blood (except reagent strip)
- 82950 – Glucose; post glucose dose (includes glucose)
- 82951 – Glucose; tolerance test (GTT), 3 specimens (includes glucose)
- 83036 – Hemoglobin A1C
Points to note:
- When submitting a claim for a diabetes screening test, the diagnosis code 1 and the ‘TS’ modifier to indicate follow-up service should be used on the claim along with the correct HCPCS/CPT code. The use of the TS modifier will reflect that the provider can be reimbursed correctly for a screening service and not for another type of diabetes testing service.
- A screening code is not necessary if the screening is inherent to a routine examination, but can be reported.
- Biennial screening mammography for breast cancer for women ages 50-74 years. The ICD-10 code for all screening mammograms, regardless of the patient’s risk status is:Z12.31 Encounter for screening mammogram for malignant neoplasm of breast Secondary codes can be assigned for any relevant clinical history, such as family history of breast cancer (Z80.3), or exam findings. For instance:Z80.3 Family history of malignant neoplasm of breastChildhood obesity is a major health problem in the U.S. Obese children and adolescents may face considerable physical and psychological morbidity. In its letter to CMS, the AAFP also stressed the importance of preventing disease and illness in patients of all ages, and notes that screening of obesity in children and adolescents is crucial to ensure their healthy development.Screening children for risk factors associated with obesity is necessary to determine which children are candidates for secondary prevention efforts. Screening involves assessing factors from the history and observing an infant or child’s growth pattern. The USPSTF-recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status. The USPSTF uses the following terms to define categories of increased BMI in children and adolescents ages 6-18 years:
- Overweight = an age/gender-specific BMI between the 85th and 95th percentiles
- Obesity = an age/gender-specific BMI at or above the 95th percentile
Expert medical coding services are available to help physicians select the right ICD-10 codes for immunizations, routine health exams, and common preventive screenings and also properly code the combination of CPT/HCPCS and ICD-10 codes. Partnering with a reliable medical billing and coding service provider can prevent claim denials and optimize reimbursement.