Transmittal 2163 Date: February 23, 2011

Transcription

1 anual ystem Pub edicare laims Processing Department of Health & Human ervices (DHH) enters for edicare & edicaid ervices () Transmittal 2163 Date: ebruary 23, 2011 hange equest 6786 Transmittal 1935, dated arch 23, 2010, is rescinded and replaced with Transmittal 2163, dated ebruary 23, The changes are to the 3 HV screening G code descriptors only, to align with the descriptors in the official code files. ll other information remains the same. UBJET: creening for the Human mmunodeficiency Virus (HV) nfection. UY O HGE: Effective January 1, 2009, the enters for edicare and edicaid ervices () is authorized to add coverage of "additional preventive services" through the national coverage determination (D) process if certain statutory requirements are met, as provided under section 101(a) of the edicare mprovements for Patients and Providers ct. One of those requirements is that the service(s) be categorized as a grade (strongly recommends) or grade B (recommends) rating by the U Preventive ervices Task orce (UPT) and meets certain other requirements. The UPT strongly recommends screening for all adolescents and adults at risk for HV infection, as well as all pregnant women. Effective for claims with dates of service on and after December 8, 2009, supports the UPT recommendations with the posting of its final decision in this regard. EETVE DTE: December 8, 2009 PLEETTO DTE: July 6, 2010 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. HGE UL TUTO: (/ if manual is not updated) =EVED, =EW, D=DELETED-Only One Per ow.

2 //D HPTE / ETO / UBETO / TTLE 18/130/TO/ Human mmunodeficiency Virus (HV) creening Tests 18/130/1/Healthcare ommon Procedure oding ystem (HP) for HV creening Tests 18/130/2/ Billing equirements 18/130/3/Payment ethod 18/130/4/Types of Bill and evenue odes for orm /130/5/Diagnosis ode eporting 18/130/6/edicare ummary otice () and laim djustment eason odes (). UDG: or iscal ntermediaries (s), egional Home Health ntermediaries (HHs): o additional funding will be provided by ; ontractor activities are to be carried out within their operating budgets. or edicare dministrative ontractors (s): V. TTHET: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

3 ttachment - Business equirements Pub Transmittal: 2163 Date: ebruary 23, 2011 hange equest: 6786 Transmittal 1935, dated arch 23, 2010, is rescinded and replaced with Transmittal 2163, dated ebruary 23, The changes are to the 3 HV screening G code descriptors only, to align with the descriptors in the official code files. ll other information remains the same. UBJET: creening for the Human mmunodeficiency Virus (HV) nfection EETVE DTE: DEEBE 8, 2009 PLEETTO DTE: JULY 6, GEEL OTO. Background: Effective January 1, 2009, the enters for edicare & edicaid ervices () is authorized to add coverage of additional preventive services through the national coverage determination (D) process if certain statutory requirements are met, as provided under section 101(a) of the edicare mprovements for Patients and Providers ct. One of those requirements is that the service(s) be categorized as a grade (strongly recommends) or grade B (recommends) rating by the U Preventive ervices Task orce (UPT) and meets certain other requirements. The UPT strongly recommends screening for all adolescents and adults at risk for HV infection, as well as all pregnant women. B. Policy: Effective for claims with dates of service on and after December 8, 2009, determines that the evidence is adequate to conclude that screening for HV infection is reasonable and necessary for early detection of HV and is appropriate for individuals entitled to benefits under Part or enrolled under Part B. Therefore will cover both standard and ood and Drug dministration (D)-approved HV rapid screening tests for: 1. One, annual voluntary HV screening of edicare beneficiaries at increased risk for HV infection per UPT guidelines and in accordance with Pub , ational overage Determinations anual (D), sections and 210.7, and Pub , edicare laims Processing anual (P), chapter 18, section 130. OTE: Eleven full months must elapse following the month in which the previous test was performed in order for the subsequent test to be covered. 2. Three, voluntary HV screenings of pregnant edicare beneficiaries at the following times: (1) when the diagnosis of pregnancy is known, (2) during the third trimester, and (3) at labor, if ordered by the woman s physician, and in accordance with Pub and Pub , as noted above. OTE: Three tests will be covered for each term of pregnancy beginning with the date of the 1 st test. OTE: The UPT guidelines upon which this policy is based contains 8 increased-risk criteria. The first 7 require the presence of both D-9 diagnosis codes V73.89 and V69.8 for the claim to be paid. The last criterion, which covers persons reporting no increased risk factors, only requires D-9 V73.89 for the claim to be paid. OTE: Patients with any known prior diagnosis of HV-related illness are not eligible for this screening test.

4 OTE: The following three new HP codes are to be implemented pril 5, 2010, effective for dates of service on and after December 8, 2009, with the pril 2010 OE and January 2011 clinical lab fee schedule (L) updates: G nfectious agent antibody detection by enzyme immunoassay (E) technique, HV-1 and/or HV-2, screening, G nfectious agent antibody detection by enzyme-linked immunosorbent assay (EL) technique, HV- 1 and/or HV-2, screening, and, G nfectious agent antibody detection by rapid antibody test, HV-1 and/or HV-2, screening. OTE: Prior to inclusion of the above G codes on the L, the above G codes shall be contractor-priced. or dates of service between December 8, 2009, and pril 4, 2010, unlisted procedure code may be used when paying for these services.. BUE EQUEET TBLE Use hall" to denote a mandatory requirement umber equirement esponsibility (place an X in each applicable column) / B D E hared-ystem aintainers OTHE Effective for claims with dates of service on and after December 8, 2009, contractors shall pay claims for HV screening tests for edicare beneficiaries subject to criteria in Pub , D, sections and 210.7, and Pub , P, chapter 18, section ontractors shall pay claims for HV screening test annually for male and female edicare beneficiaries containing HP codes G0432, G0433, or G0435, along with D-9 diagnosis codes V73.89 (special screening for other specified viral disease) as primary, when no increased risk factors are reported ontractors shall pay claims for HV screening test annually for male and female edicare beneficiaries containing HP codes G0432, G0433, or G0435, along with D-9 diagnosis codes V73.89 as primary, and V69.8 (other problems related to lifestyle), as secondary, when increased risk factors are reported ontactors shall pay claims for pregnant female edicare beneficiaries containing HP codes G0432, G0433, or G0435 with D-9 diagnosis codes V73.89, along with one of the following D-9 diagnosis codes as secondary: V22.0 (supervision of normal first pregnancy), V22.1 (supervision of other normal pregnancy), or V23.9 (supervision of unspecified high-risk pregnancy). E X X X H H V W X X X X 4/2010 OE X X X X X X X X ontractors shall pay claims for HV screening tests X X X 1/2011 L

5 umber equirement esponsibility (place an X in each applicable column) / B D E hared-ystem aintainers OTHE containing HP codes G0432, G0433, or G0435 on TOBs 12X, 13X, 14X, 22X, and 23X, under the clinical lab fee schedule. Deductible and coinsurance do not apply. E H H V W OTE: Prior to inclusion in the L, the above G codes shall be contractor-priced. Between December 8, 2009, and pril 4, 2010, unlisted procedure code may be used ontractors shall pay claims for HV screening tests containing HP codes G0432, G0433, or G0435 on TOB 85X under reasonable cost ontractors shall only allow HP codes G0432, G0433, or G0435 with D-9 codes V73.89, V69.8, and V22.0, V22.1, or V23.9 (for pregnant female edicare beneficiaries), to be billed with revenue code 030X ontractors shall deny claims for HV screening tests billed without HP codes G0432, G0433, or G0435 and D-9 diagnosis codes V73.89, or V73.89 and V69.8 (when increased risk factors are reported) using the following messages: X X X X X X X X X edicare does not pay for this item or service. edicare no paga por este articulo o servicio 167- This (these) diagnosis(es) is (are) not covered. OTE: f an advance beneficiary notice (B) is provided, use Group ode P (Patient esponsibility). f an B is not provided, use Group ode O (ontractual Obligation) Effective for claims with dates of service on or after December 8, 2009, W shall create an edit to allow no more than 1 HV screening test annually containing HP codes G0432, G0433, or G0435 and D-9 code V73.89, with the exception in 7.1 below. Eleven full months must elapse following the month in which the previous test was performed in order for the subsequent test to be covered Effective for claims with dates of service on or after December 8, 2009, W shall create an edit to allow no X X

6 umber equirement esponsibility (place an X in each applicable column) / B D E hared-ystem aintainers OTHE more than 3 HV screening tests during each term of pregnancy beginning with the date of the 1 st test containing HP codes G0432, G0433, or G0435 and D-9 code V73.89 and accompanied by one of the diagnosis codes V22.0, V22.1, or V23.9. E H H V W OTE: W shall allow this edit to be overridable back to the contractor for an & determination ontractors shall deny claims due to the frequency limitations in Bs.7 and 7.1 above using the following messages: X X X X The information provided does not support the need for this many services or items in this period of time so edicare will not pay for this item or service. n proporcionada no justifica la necesidad de esta cantidad de servicios o articulos en este periodo por este articulo o servicio. 119 Benefit maximum for this time period or occurrence has been reached. OTE: f an B is provided, use Group ode P. f an B is not provided, use Group ode O Effective for claims with dates of service on and after December 8, 2009, W shall update ajor ategory V for B to include HP G0432, G0433, or G0435 in order to allow only 22X bill types to bypass B edits Effective for claims with dates of service on and after December 8, 2009, contractors shall pay for HV screening tests for hospitals in aryland under the jurisdiction of the Health ervices ost eview ommission, TOBs 12X, 13X, or 14X, on an inpatient Part B or outpatient basis in accordance with the terms of the aryland waiver or claims with dates of service between December 8, 2009, and July 5, 2010, contractors shall not massadjust claims but shall adjust claims brought to their attention. X X X X X X X. POVDE EDUTO TBLE

7 umber equirement esponsibility (place an X in each applicable column) /B DE E HH hared-ystem aintainers OTHE V W X X X provider education article related to this instruction will be available at s/ shortly after the is released. You will receive notification of the article release via the established "L atters" listserv. ontractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in your next regularly scheduled bulletin. ontractors are free to supplement L atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. V. UPPOTG OTO ection : or any recommendations and supporting information associated with listed requirements, use the box below: Use "hould" to denote a recommendation. X-ef equirement umber / ecommendations or other supporting information: ection B: or all other recommendations and supporting information, use this space: / V. OTT Pre-mplementation ontact(s): William uiz, nstitutional laims, , William.uiz@cms.hhs.gov, Thomas Dorsey, Practitioner laims, , Thomas.Dorsey@cms.hhs.gov, pril Billingsley, Practitioner laims, , pril.billingsley@cms.hhs.gov, Pat Brocato-imons, overage, , patricia.brocatosimons@cms.hhs.gov. Post-mplementation ontact(s): ontact your ontracting Officer s Technical epresentative (OT) or ontractor anager, as applicable. V. UDG ection : or iscal ntermediaries (s), egional Home Health ntermediaries (HHs): o additional funding will be provided by ; contractor activities are to be carried out within their operating budgets.

8 ection B: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the contracting officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the contracting officer, in writing or by , and request formal directions regarding continued performance requirements.

9 edicare laims Processing anual hapter 18 - Preventive and creening ervices Table of ontents (ev. 2163, ) Healthcare ommon Procedure oding ystem (HP) for HV creening Tests Billing equirements Payment ethod(s) Types of Bill (TOBs) and evenue odes Diagnosis ode eporting edicare ummary otice () and laim djustment eason odes ()

10 130 Healthcare ommon Procedure oding ystem (HP) for HV creening Tests (ev. 2163, ssued: , Effective: , mplementation: ) Effective for claims with dates of service on and after December 8, 2009, implemented with the pril 5, 2010, OE, the following HP codes are to be billed for HV screening: G0432- nfectious agent antibody detection by enzyme immunoassay (E) technique, HV-1 and/or HV-2, screening, G nfectious agent antibody detection by enzyme-linked immunosorbent assay (EL) technique, HV-1 and/or HV-2, screening, and, G nfectious agent antibody detection by rapid antibody test, HV-1 and/or HV-2, screening Billing equirements (ev. 2163, ssued: , Effective: , mplementation: ) Effective for dates of service December 8, 2009, and later, contractors shall recognize the above HP codes for HV screening. edicare contractors shall pay for voluntary HV screening as follows in accordance with Pub , edicare ational overage Determinations anual, sections and 210.7: maximum of once annually for beneficiaries at increased risk for HV infection (11 full months must elapse following the month the previous test was performed in order for the subsequent test to be covered), and, maximum of three times per term of pregnancy for pregnant edicare beneficiaries beginning with the date of the first test when ordered by the woman s clinician. laims that are submitted for HV screening shall be submitted in the following manner: or beneficiaries reporting increased risk factors, claims shall contain HP code G0432, G0433, or G0435 with diagnosis code V73.89 (pecial screening for other specified viral disease) as primary, and V69.8 (Other problems related to lifestyle), as secondary. or beneficiaries not reporting increased risk factors, claims shall contain HP code G0432, G0433, or G0435 with diagnosis code V73.89 only. or pregnant edicare beneficiaries, claims shall contain HP code G0432, G0433, or G0435 with diagnosis code V73.89 as primary, and one of the following D-9 diagnosis codes: V22.0 (upervision of normal first pregnancy), V22.1 (upervision of other normal pregnancy), or V23.9 (upervision of unspecified high-risk pregnancy), as secondary.

11 Payment ethod (ev. 2163, ssued: , Effective: , mplementation: ) Payment for HV screening is under the edicare linical Laboratory ee chedule for TOBs 12X, 13X, 14X, 22X, and 23X beginning January 1, or TOB 85X payment is based on reasonable cost. Deductible and coinsurance do not apply. Between December 8, 2009, and pril 4, 2010, these services can be billed with unlisted procedure code Between pril 5, 2010, and January 1, 2011, the G codes will be contractor priced Types of Bill (TOBs) and evenue odes (ev. 2163, ssued: , Effective: , mplementation: ) The applicable bill types for HV screening are: 12X, 13X, 14X, 22X, 23X, and 85X. (Effective pril 1, 2006, TOB 14X is for non-patient laboratory specimens.) Use revenue code 030X (laboratory, clinical diagnostic) Diagnosis ode eporting (ev. 2163, ssued: , Effective: , mplementation: ) claim that is submitted for HV screening shall be submitted with one or more of the following diagnosis codes in the header and pointed to the line item: a. or claims where increased risk factors are reported: V73.89 as primary and V69.8 as secondary. b. or claims where increased risk factors are OT reported: V73.89 as primary only. c. or claims for pregnant edicare beneficiaries, the following diagnosis codes shall be submitted in addition to V73.89 to allow for more frequent screening than once per 12-month period: V22.0 upervision of normal first pregnancy, or, V22.1 upervision of other normal pregnancy, or, V upervision of unspecified high-risk pregnancy) edicare ummary otice () and laim djustment eason odes () (ev. 2163, ssued: , Effective: , mplementation: ) a. When denying claims for HV screening submitted without D-9 diagnosis codes V73.89, or V73.89 and V69.8, use the following messages: edicare does not pay for this item or service. edicare no paga por este articulo o servicio

12 167- This (these) diagnosis(es) is (are) not covered. Group ode O (ontractual Obligation) b. When denying claims for HV screening, use the following denial messages: The information provided does not support the need for this many services or items in this period of time so edicare will not pay for this item or service. n proporcionada no justifica la necesidad de esta cantidad de servicios o articulos en este periodo por este articulo o servicio. 119 Benefit maximum for this time period or occurrence has been reached. Group ode O (ontractual obligation).