CMS
Publication Date: December 17, 2004
Effective Date: January 01, 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.

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.

The following HCPCS/CPT Codes are to be billed for the Cardiovascular Screening Blood Tests:

• 80061 Lipid Panel
• 82465 Cholesterol, serum, or whole blood, total
• 83718 Lipoprotein, direct measurement; high-density cholesterol
• 84478 Triglycerides

(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 when billing for cardiovascular screening blood test:

• V81.0 Special Screening for ischemic heart disease
• V81.1 Special Screening for hypertension
• 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.

Reference: Medicare Matters  MM3411.

CMS
Publication Date: December 21, 2004
Effective Date: January 01, 2005

Medicare will permit coverage for the following diabetes screening tests for services performed on or after January 1, 2005 for individuals who satisfy the eligibility requirements of being at risk for diabetes:

1. Fasting plasma glucose test; and
2. Post-glucose challenge test

Coverage will be provided for two screening tests per calendar year for individuals diagnosed with pre-diabetes, and one screening test per year for individuals previously tested who were not diagnosed with pre-diabetes, or who have never been tested. This coverage does not apply to individuals previously diagnosed as diabetic.

Any individual with one (1) of the following individual risk factors for diabetes is eligible for this new benefit:

1. Hypertension,
2. Dyslipidemia,
3. Obesity (with a body mass index greater than or equal to 30 kg/m2), or
4. Previous identification of elevated impaired fasting glucose or glucose intolerance.

Or, an individual with any two (2) of the following risk factors for diabetes is also eligible for this new benefit:

1. Overweight (a body mass index >25, but<30kg/m2),
2. A family history of diabetes,
3. Age 65 years or older, or
4. A history of gestational diabetes mellitus or giving birth to a baby weighing > 9 lb.

Reference: Transmittal 409  CR 3637.

CMS
Publication Date: October 29, 2004
Effective Date: April 01, 2005

Effective April 01, 2005, a new edit will be established in Medicare systems to check for duplicate claims for referred clinical diagnostic laboratory services and purchased diagnostic services submitted by physicians/suppliers to more than one carrier.

Claims submitted for referred clinical diagnostic/purchased diagnostic services will be identified as "duplicate claims" when the involved claims contain different carrier numbers and all of the following data matches in the claim fields:

1. Beneficiary Name;
2. Beneficiary Health Insurance Claim Number (HICN);
3. Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code;
4. Date of Service; and
5. CPT/HCPCS Code Modifier.

Reference: Medicare Matters  MM3551.

CMS

Publication Date: December 17, 2004
Effective Date: January 01, 2005

CMS issued an Emergency Change to Carrier Instructions for the End Stage Renal Disease (ESRD) 50/50 Rule Implementation notifying carriers to discontinue the implementation of the business requirements associated with CR 2813 (ESRD Reimbursement for Automated Multi-Channel Chemistry Test(s)) until further notice.

Reference: Medicare Matters  MM3609.

CMS
Publication Date: October 22, 2004
Effective Date: January 01, 2005

Effective for dates of service on or after January 1, 2005, Section 611 of the Medicare Modernization Act provides for coverage under Part B of an initial preventive physical examination (IPPE) for new Medicare beneficiaries, but only if the beneficiary’s eligibility also begins on or after January 01, 2005.

Lab services included in the initial exam include screening PAP smear, screening PSA, cardiovascular screening blood tests and diabetes screening tests.

Reference: Transmittal 414  CR 3638.

CMS
Publication Date: November 26, 2004
Effective Date: January 01, 2005

CR  3429 announces changes that will be included in the January 2005 release of the edit module for clinical diagnostic laboratory services. In accordance with the coding analysis published on the coverage Internet site on July 26, 2004, CMS is implementing the following:

• For the urine culture and serum iron studies NCD, CMS is deleting the following ICD-9-CM code from the list of ICD-9-CM codes covered by Medicare: V72.84 (Pre-operative examination, unspecified).

Coverage for this code will terminate for services furnished on or after January 1, 2005. See: Decision Memo  127. In accordance with the coding analysis published on the coverage Internet site on July 27, 2004, CMS is implementing the following changes:

• For the tumor antigen by immunoassay CA 125 NCD, CMS is adding the following ICD-9-CM diagnosis codes to the list of ICD-9-CM codes covered by Medicare:
  • V10.41 (Personal history of malignant neoplasm, cervix uteri); and
  • V10.42 (Personal history of malignant neoplasm, other parts of uterus).

Coverage for these codes will begin for services furnished on or after January 1, 2005. See: Decision Memo  132. In accordance with the coding analysis published on the coverage Internet site on July 28, 2004, CMS is implementing the following change:

• For the Prothrombin Time (PT) test NCD, CMS is removing the following ICD-9-CM diagnosis code from the list of ICD-9-CM codes covered by Medicare: V43.60 (Unspecified joint replaced by other means).

Coverage for this code will terminate for services furnished on or after January 01, 2005. See: Decision Memo  131.

To accommodate the new cardiovascular and diabetes screening benefits that were added to Medicare by the MMA, CMS is removing the following ICD-9-CM codes from the list of ICD-9-CM codes not covered by Medicare:

• V77.1 (Screening for Diabetes Mellitus);
• V81.0 (Screening for Ischemic Heart Disease);
• V81.1 (Screening for Hypertension); and
• V81.2 (Screening for Other Unspecified Cardiovascular Conditions).

In order to implement the new cardiovascular and diabetes screening benefits that were added to Medicare by the MMA, CMS is making the following changes:

The lipid NCD edit is being subdivided into two parts:

• For Current Procedural Terminology (CPT) codes 80061 (Lipid panel), 82465 (Cholesterol, serum total), 83718 (Lipoprotein, direct, HDL), and 84478 (Triglycerides), CMS is adding the following ICD-9-CM diagnosis codes to the list of ICD-9-CM Codes covered by Medicare:
• V81.0 (Screening for Ischemic Heart Disease);
• V81.1 (Screening for Hypertension); and
• V81.2 (Screening for Other Unspecified Cardiovascular Conditions).
• The covered codes list for the remaining CPT codes in the lipid NCD (83715 [Lipoprotein, blood: electrophoretic separation and quantitation]), 83716 (High resolution fractionation and quantitation of lipoprotein cholesterols), and 83721 (Direct measurement, LDL cholesterol)) remain unchanged.

For the diabetes benefit, the blood glucose NCD edit is being subdivided into two parts:

• For CPT code 82947, CMS is adding the following ICD-9-CM diagnosis code to the list of ICD-9-CM Diagnosis Codes covered by Medicare: V77.1 (Screening for Diabetes Mellitus).
• The covered codes for the remaining CPT codes in the blood glucose NCD (82948 (Glucose, blood, strip) and 82962 (Glucose (monitors)) remain unchanged.

NHIC - California (Northern and Southern)
Publication Date: December 23,2004

Genomic Health, Inc. (www.genomichealth.com) has developed a laboratory test which can be performed on paraffin-embedded breast cancer tissue ("Oncotype DX"^TM). The test is proposed to forecast prognostic factors and help guide therapeutic interventions more effectively than traditional breast cancer diagnostics.

At this time, NHIC California does not provide coverage for the Oncotype DX test, because Oncotype DX has not been determined to be reasonable and necessary for care.

NHIC notes that the test is not FDA-approved; and that as of late 2004, published noncoverage/experimental decisions were also found at private, Blue Cross, and governmental healthcare websites.

Billing Guidelines - Claims which fall under the jurisdiction of NHIC Part B as described above, may be submitted to NHIC for denial purposes for secondary insurers in conjunction with an Advance Beneficiary Notice (ABN) or to initiate appeal rights. An ABN is appropriate when there is a benefit category (laboratory tests; cancer care) but a particular service is not reasonable and necessary. The test should be submitted as CPT code 84999 (unlisted chemistry procedure) because the most closely relevant codes are those for DNA analysis such as polymerase chain reaction (PCR). Indicate in the comment field that the test is "Oncotype DX". CPT code 84999 should be submitted as a global fee only (do NOT submit with the -26 and -TC modifiers). CPT code 89240 (unlisted miscellaneous pathology test) should not be used since it refers to anatomic pathology tests.

Reference: Article for Oncotype DX Test for Breast Cancer Tissue Samples  A24749/A24753.

NHIC - California
Publication Date: June 06, 2003
Effective Date: October 01, 2003

All Medicare claims must be billed to Part B carriers with a valid diagnosis code with the exception of Ambulance suppliers. Carriers will return as unprocessable, claims that do not contain a valid diagnosis code in item 21 of the CMS -1500 claim form or equivalent electronic field (HI segment - Loop 2300). Enter up to 4 codes in priority order (primary, secondary condition).

Reference: Medlearn Matters  SE0306.

California - Medi-cal
Publication Date: December 2004
Effective Date: January 01, 2005

Current Medi-Cal policy requires providers to bill using the highest level of diagnosis code available on a given date of service. Effective January 01, 2005, claims billed with an invalid diagnosis code will be returned.

Reference Medi-Cal Update, General Medicine  Bulletin 365.

California - Medi-Cal
Publication Date: December 2004

The list of providers on the Procedure/Drug Code Limitation List (P/DCL List) is being published in the Medi-Cal Update and is also available on the Medi-Cal Web site. Additions and changes display in bold type. Providers placed on the P/DCL List are not eligible to receive reimbursement for the procedure or drug code services for which the providers are under restriction. In addition, other providers who fill orders for lab tests, drugs, medical supplies or any other restricted services prescribed or ordered by the provider under restriction will not be reimbursed. The limitation becomes effective after the Department of Health Services gives the provider notice of the proposed limitation and no appeal is submitted within 45 days, or following denial of an appeal. After 18 months, the P/DCL automatically ceases.

Reference Medi-Cal Update, General Medicine  Bulletin 365.