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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
R
Official CMS Information for
Medicare Fee-For-Service Providers
Cardiovascular Disease Services
ICN 907784 July 2012
Cardiovascular Disease Services
DISCLAIMER
This booklet was current at the time it was published or uploaded onto the web. Medicare policy changes frequently
so links to the source documents have been provided within the document for your reference.
This booklet was prepared as a service to the public and is not intended to grant rights or impose obligations. This
booklet 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.
ICD-9-CM Notice
The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is published by the
United States Government. A CD-ROM, which may be purchased through the Government Printing Office, is the
only official Federal government version of the ICD-9-CM. ICD-9-CM is an official Health Insurance Portability
and Accountability Act standard.
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American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules,
relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of
CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or
dispense medical services. The AMA assumes no liability for data contained or not contained herein.
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Cardiovascular Disease Services
Table of Contents
Overview ..................................................................................................................... 2
Cardiovascular Disease Screening Blood Tests....................................................... 3
Coverage Information ....................................................................................... 3
Documentation.................................................................................................... 4
Coding and Diagnosis Information................................................................... 5
Billing Requirements.......................................................................................... 6
Payment Information......................................................................................... 9
Reasons for Claim Denial................................................................................ 10
Intensive Behavioral Therapy (IBT) for Cardiovascular Disease....................... 10
Coverage Information...................................................................................... 10
Documentation.................................................................................................. 12
Coding and Diagnosis Information................................................................. 13
Billing Requirements ....................................................................................... 13
Payment Information. 15
Reasons for Claim Denial. 16
Resources. 17
1
Cardiovascular Disease Services
The Centers for Medicare & Medicaid Services (CMS) recognizes
the crucial role that health care providers play in educating Medicare
beneficiaries about potentially life-saving preventive services and
screenings, and in providing these services. While Medicare pays for
a variety of preventive benefits, many Medicare beneficiaries do not
fully realize that using preventive services and screenings can help
them live longer, healthier lives. As a health care professional, you
can help your Medicare beneficiaries understand the importance of
disease prevention, early detection, and lifestyle modifications that
support a healthier life. This booklet can help you communicate with
your beneficiaries about Medicare-covered cardiovascular disease
screening blood tests and Intensive Behavioral Therapy (IBT) for
cardiovascular disease, as well as assist you in correctly billing for
these services.
Overview
Cardiovascular disease (hypertension, coronary
heart disease, heart failure, and stroke) is the
leading cause of mortality and hospitalizations in
the U.S.
Medicare began covering cardiovascular disease
screening blood tests in 2005, for the purpose
of early detection of cardiovascular disease in
individuals without apparent signs or symptoms
of cardiovascular disease.
Removal of Barriers to Preventive Services
Under the Affordable Care Act
Medicare waives the coinsurance or copayment and
deductible for those Medicare-covered preventive
services recommended by the United States Preventive
Services Task Force (USPSTF) with a grade of A or B
for any indication or population, and that are appropriate
for the individual.
Effective for dates of service on or after November 8, 2011, Medicare also provides coverage of IBT
for cardiovascular disease. This face-to-face visit helps beneficiaries and their health care providers
to reduce the risk of cardiovascular disease.
CMS recommends that all eligible beneficiaries take advantage of the Medicare coverage of these
cardiovascular disease services.
Risk Factors
Million Hearts (TM)
Risk factors for developing cardiovascular
disease include the following:
Million Hearts (TM) is a national initiative to prevent
1 million heart attacks and strokes by 2017. It is
co-led by the Centers for Disease Control and Prevention
(CDC) and CMS, working alongside other Federal
agencies and key private-sector partners. For more
information, visit http://millionhearts.hhs.gov on
the Internet.
► Being overweight;
► Obesity;
► Physical inactivity;
► Diabetes;
2
Cardiovascular Disease Services
► Cigarette smoking;
► High blood pressure;
► High blood cholesterol;
► Family history of myocardial infarction; and
► Older age.
Cardiovascular Disease Screening Blood Tests
Coverage Information
Medicare Part B covers cardiovascular disease
screening blood tests every 5 years (i.e., at
least 59 months after the most recent screening
tests) for beneficiaries without apparent signs or
symptoms of cardiovascular disease.
The cardiovascular disease screening blood tests
Medicare covers include the following:
► Total Cholesterol Test,
► Cholesterol Test for High Density
Lipoproteins (HDL), and
Stand Alone Benefit
The cardiovascular disease screening blood test benefit
covered by Medicare is a stand alone billable service.
It is separate from the Initial Preventive Physical
Examination (IPPE) or the Annual Wellness Visit
(AWV), although it can be provided at the same time as
the IPPE or AWV. Medicare beneficiaries may obtain
cardiovascular disease screening blood tests at any time
following Medicare Part B enrollment, subject to the
frequency limitations we have described in this section.
► Triglycerides Test.
These tests are the only screening blood tests Medicare covers as part of this preventive service. You
may order these tests individually or together as a lipid panel.
NOTE: Since direct measurement Low Density Lipoprotein (LDL) is not part of the cardiovascular
disease screening blood tests benefit, CMS encourages you to order lipid panels without
the direct measurement LDL option to protect Medicare beneficiaries from incurring
a charge for this service without advance notice. Laboratories must offer the ability to
order a lipid panel without the LDL measurement. If the screening lipid panel results
indicate a triglyceride level that indicates the need for a direct measurement LDL, the
physician may order this test once the results of the screening lipid panel are reported.
For more information, refer to the “Medicare National Coverage Determination Manual,”
Publication 100-03, Part 3, Section 190.23 at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/ncd103c1_Part3.pdf on the CMS website.
3
Cardiovascular Disease Services
Frequency
When calculating frequency to determine the
5-year period, 59 months must elapse following
the month in which the last cardiovascular disease
screening blood test took place.
EXAMPLE: A beneficiary gets a cardiovascular
disease screening blood test in January 2012.
The count starts February 2012. The beneficiary
may get another cardiovascular disease screening
blood test in January 2017.
Who Are Qualified Physicians and
Non-Physician Practitioners?
For the purpose of ordering the cardiovascular disease
screening blood tests benefit:
Physician
A physician is a doctor of medicine or osteopathy.
Non-Physician Practitioner
A qualified non-physician practitioner is a:
NOTE: The frequency limit for each test applies
regardless of whether you provide it in a
panel or individually.
Clinical nurse specialist,
Nurse practitioner, or
Physician assistant.
Coinsurance or Copayment and Deductible
The beneficiary pays nothing (no coinsurance or copayment and no Medicare Part B deductible)
for cardiovascular disease screening blood tests if conditions of coverage are met. However, if a
beneficiary sees a non-participating physician, there could be a charge.
Documentation
Medical records must document that all coverage requirements are met. Documentation must show
that a physician or qualified non-physician practitioner treating an asymptomatic beneficiary ordered
the cardiovascular disease screening blood test for the purpose of early detection of cardiovascular
disease. The beneficiary must fast for 12 hours prior to the test. You should document the appropriate
supporting procedure and diagnosis codes.
4
Cardiovascular Disease Services
Coding and Diagnosis Information
Procedure Codes and Descriptors
Use the following Current Procedural Terminology (CPT) codes to report cardiovascular disease
screening blood tests.
Table 1. CPT Codes for Cardiovascular Disease Screening Blood Tests*
CPT Code
Code Descriptor
80061
Lipid Panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol
(HDL cholesterol) (83718)
Triglycerides (84478)
82465
Cholesterol, serum or whole blood, total
83718
Lipoprotein, direct measurement; high density cholesterol
(HDL cholesterol)
84478
Triglycerides
* You should order the tests as a lipid panel; however, you may order them individually. To ensure
that Medicare and Medicaid only pay for a laboratory test categorized as “Waived Complexity”
under the Clinical Laboratory Improvement Amendments (CLIA), bill these CPT codes with
modifier QW.
CPT only copyright 2011 American Medical Association. All rights reserved.
5
Cardiovascular Disease Services
Diagnosis Requirements
You must report one or more of the
following International Classification of
Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) screening (“V”) diagnosis code(s)
for cardiovascular disease screening blood tests.
Coming Soon!
International Classification of Diseases, 10th
Revision, Clinical Modification/Procedure
Coding System (ICD-10-CM/PCS)
For more information, visit http://www.cms.gov/
Medicare/Coding/ICD10 on the CMS website.
Table 2. Diagnosis Codes for Cardiovascular Disease Screening Blood Tests
ICD-9-CM Diagnosis Code
Code Descriptor
V81.0
Special screening for ischemic heart disease
V81.1
Special screening for hypertension
V81.2
Special screening for other and unspecified
cardiovascular conditions
Billing Requirements
Billing and Coding Requirements When Submitting Professional Claims
When you submit professional claims to carriers or A/B Medicare Administrative Contractors
(MACs), report the appropriate CPT code and the corresponding ICD-9-CM diagnosis code in
the X12 837-P (Professional) electronic claim format. You must also include Place of Service
(POS) codes on all professional claims, to indicate where you provided the service. For more
information on POS codes, visit http://www.cms.gov/Medicare/Coding/place-of-service-codes
on the CMS website.
NOTE:If you qualify for an exception to Electronic Claims Requirements
the Administrative Simplification
Compliance Act (ASCA) requirement, ASCA requires providers to submit claims to
Medicare electronically, with limited exceptions.
you may use Form CMS-1500 to submit For more information about the electronic formats,
these claims on paper. All providers visit http://www.cms.gov/Medicare/Billing/
must use Form CMS-1500, version
ElectronicBillingEDITrans/HealthCareClaims.html
08-05, when submitting paper claims. on the CMS website.
For more information on Form
CMS-1500, visit http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/16_1500.
html on the CMS website.
6
Cardiovascular Disease Services
Billing and Coding Requirements When Submitting Institutional Claims
When you submit institutional claims to Fiscal Intermediaries (FIs) or A/B MACs, report the
appropriate CPT code, revenue code, and the corresponding ICD-9-CM diagnosis code in the
X12 837-I (Institutional) electronic claim format.
NOTE: If an institution qualifies for an exception to the ASCA requirement, it may use
Form CMS-1450 to submit these claims on paper. All providers must use Form CMS-1450
(UB-04) when submitting paper claims. For more information on Form CMS-1450, visit
http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/15_1450.html on the
CMS website.
Types of Bill (TOBs) for Institutional Claims
The FI or A/B MAC pays for cardiovascular disease screening blood tests when you submit on
the following TOBs. For further guidance on the appropriate revenue code, contact your local
Medicare Contractor.
Table 3. Facility Types and TOBs for Cardiovascular Disease Screening Blood Tests
Facility Type
TOB
Hospital Inpatient (Part B)
12X
Hospital Outpatient
13X
Hospital Other Part B (Non-Patient Laboratory Specimens including
Critical Access Hospital [CAH])
14X
Skilled Nursing Facility (SNF) Inpatient Part B
22X
SNF Outpatient
23X
Federally Qualified Health Center (FQHC)
77X
CAH*
85X
*A beneficiary does not need to be
physically present in a CAH when
a specimen is collected, but must be
an outpatient of the CAH. Either the
beneficiary must get outpatient services in
the CAH on the same day the specimen
is collected, or an employee of the CAH
or an entity that is provider-based to the
CAH must collect the specimen.
Copyright © 2011, the American Hospital Association, Chicago, Illinois. Reproduced with permission.
No portion of this publication may be copied without the express written consent of the AHA.
7
Cardiovascular Disease Services
Additional Billing Instructions for FQHCs and Rural Health Clinics (RHCs)
The professional component of preventive services is within the scope of covered FQHC or RHC
services. The professional component is a physician’s interpretation of the results of an examination.
For instructions on billing the professional component, visit http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1039.pdf
on the CMS website.
RHCs are not included in Table 3. RHCs may only bill for RHC services; laboratory services are not
within the scope of the RHC benefit. However, if the RHC is provider-based and the base provider
furnishes the laboratory test apart from the RHC, then the base provider may bill the laboratory test
using the base provider’s provider ID number. Medicare will make payment to the base provider,
not to the RHC. If the facility is freestanding, then the individual practitioner bills the carrier or
A/B MAC for the laboratory test using the provider ID number.
The technical component is services rendered outside the scope of the physician’s interpretation of
the results of an examination. If you perform technical components or services, not within the scope
of covered FQHC services, in association with professional components, how you bill depends on
whether the FQHC is independent or provider-based:
► For Provider-Based FQHCs: Bill the technical component of the service on the TOB for the
base provider and submit to the FI or A/B MAC in the 837-I format. For more information on
billing instructions for provider-based FQHCs, visit http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html on the
CMS website and choose the appropriate chapter based on your facility type.
► For Independent FQHCs: Bill the technical component of the service to the carrier or
A/B MAC in the 837-P format. For more information on billing instructions for independent
FQHCs, visit http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/
clm104c12.pdf and http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/clm104c26.pdf on the CMS website.
8
Cardiovascular Disease Services
Payment Information
Professional Claims
Providers Must Use EFT
When you bill your carrier or A/B MAC,
Medicare pays for cardiovascular disease
screening blood tests under the Clinical
Laboratory Fee Schedule.
Institutional Claims
All providers enrolling in the Medicare Program
for the first time, changing existing enrollment data,
or revalidating enrollment must use Electronic Funds
Transfer (EFT) to get payments. For more information
about EFT, visit http://www.cms.gov/Medicare/
Billing/ElectronicBillingEDITrans/EFT.html
on the CMS website.
When you bill your FI or A/B MAC, Medicare payment for cardiovascular disease screening blood
tests depends on the type of facility providing the service. Table 4 lists the type of payment that
facilities get.
Table 4. Facility Payment Methods for Cardiovascular Disease Screening Blood Tests
Facility Type
Basis of Payment
Hospital Inpatient (Part B)
Clinical Laboratory Fee Schedule
Hospital Outpatient
Clinical Laboratory Fee Schedule
Hospital Other Part B (Non-Patient
Laboratory Specimens including CAH)
Clinical Laboratory Fee Schedule
SNF Inpatient Part B*
Clinical Laboratory Fee Schedule
SNF Outpatient
Clinical Laboratory Fee Schedule
Method I: 101% of reasonable cost for technical
component(s) of services
CAH
Method II: 101% of reasonable cost for technical
component(s) of services, plus 115% of Medicare
Physician Fee Schedule (MPFS) non-facility rate
for professional component(s) of services
FQHC
All-Inclusive Payment Rate
*The SNF consolidated billing provision allows separate Medicare Part B payment for
cardiovascular disease screening blood tests for beneficiaries in a skilled Part A stay; however,
the SNF must submit these services on a 22X TOB. Cardiovascular disease screening blood tests
provided by other facility types for beneficiaries in a skilled Part A stay must be paid by the SNF.
Copyright © 2011, the American Hospital Association, Chicago, Illinois. Reproduced with permission.
No portion of this publication may be copied without the express written consent of the AHA.
9
Cardiovascular Disease Services
Reasons for Claim Denial
Medicare may deny coverage of cardiovascular
disease screening blood tests in several situations,
including:
► The beneficiary got a covered lipid panel
during the past 5 years.
► The beneficiary got the same individual
cardiovascular disease screening blood test
during the past 5 years.
Medicare Contractor Contact Information
F o r c a r r i e r, F I , o r A / B M A C c o n t a c t
information, visit http://www.cms.gov/ResearchStatistics-Data-and-Systems/MonitoringPrograms/Provider-Compliance-Interactive-Map
on the CMS website.
You may find specific payment decision
RA Information
information on the Remittance Advice
(RA). The RA includes Claim Adjustment For more information about the RA, visit http://www.
Reason Codes (CARCs) and Remittance
cms.gov/Medicare/Billing/ElectronicBillingEDITrans/
Advice Remark Codes (RARCs) that Remittance.html on the CMS website.
provide additional information on payment
adjustments. For the most current listing of these codes, visit http://www.wpc-edi.com/reference
on the Internet. You can obtain additional information about claims from your carrier,
FI, or A/B MAC.
Intensive Behavioral Therapy (IBT)
for Cardiovascular Disease
Coverage Information
Medicare Part B covers annual (i.e., at least
11 months after the most recent IBT session for
cardiovascular disease) IBT for cardiovascular
disease, also referred to as a cardiovascular
disease risk reduction visit. IBT for
cardiovascular disease consists of the following
three components:
Stand Alone Benefit
The IBT for cardiovascular disease benefit covered
by Medicare is a stand alone billable service. It
is separate from the IPPE or the AWV, although
it can be provided at the same time as the IPPE
or AWV. Medicare beneficiaries may obtain IBT
for cardiovascular disease at any time following
Medicare Part B enrollment, subject to the frequency
limitations we have described in this section.
► Encouraging aspirin use for the primary
prevention of cardiovascular disease when
the benefits outweigh the risks for men
aged 45 through 79 years and women aged 55 through 79 years;
► Screening for high blood pressure in adults aged 18 and older; and
► Intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia,
hypertension, advancing age, and other known risk factors for cardiovascular- and
diet-related chronic disease.
10
Cardiovascular Disease Services
Medicare covers one cardiovascular disease risk reduction visit each year for beneficiaries who
are competent and alert at the time counseling is provided and whose counseling is furnished by
a qualified primary care physician or other primary care practitioner and in a primary care setting.
Only a small proportion of the Medicare population is under age 45 (men) or 55 (women).
Therefore, the majority of beneficiaries should get all three components of this benefit. Intensive
behavioral counseling to promote a healthy diet is broadly recommended for nearly 100 percent of
the population due to the prevalence of known risk factors.
The behavioral counseling intervention for aspirin use and a healthy diet should be consistent with
the 5A’s approach adopted by the USPSTF to describe such services.
1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of
behavior change goals or methods;
2. Advise: Give clear, specific, and personalized behavior change advice, including
information about personal health harms and benefits;
3. Agree: Collaboratively select appropriate treatment goals and methods based on the
beneficiary’s interest in and willingness to change the behavior;
4. Assist: Using behavior change techniques (self-help and/or counseling), aid the
beneficiary in achieving agreed-upon goals by acquiring the skills, confidence, and social/
environmental supports for behavior change, supplemented with adjunctive medical
treatments when appropriate; and
5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing
assistance/support and to adjust the treatment plan as needed, including referral to more
intensive or specialized treatment.
11
Cardiovascular Disease Services
Primary Care Setting Defined
For purposes of this covered benefit, a primary care setting is defined as one in which there is
the provision of integrated, accessible health care services by clinicians who are accountable for
addressing a large majority of personal health care needs, developing a sustained partnership with
patients, and practicing in the context of family and community. The following are not considered
primary care settings under this definition:
► Ambulatory surgical centers,
► Emergency departments,
► Hospices,
► Independent diagnostic testing facilities,
► Inpatient hospital settings,
► Inpatient rehabilitation facilities, and
► Skilled nursing facilities.
Medicare covers IBT for cardiovascular disease in primary care provided in:
► An office,
► An outpatient hospital,
► An independent clinic, or
► A rural health clinic.
Frequency
When calculating frequency to determine the annual period, 11 full months must elapse following
the month in which the last IBT for cardiovascular disease session took place.
EXAMPLE: A beneficiary gets IBT for cardiovascular disease in January 2012. The count
starts February 2012. The beneficiary may get another IBT session for cardiovascular disease in
January 2013.
Coinsurance or Copayment and Deductible
The beneficiary pays nothing (no coinsurance or copayment and no Medicare Part B deductible) for
IBT for cardiovascular disease if conditions of coverage are met. However, if a beneficiary sees a
non-participating physician, there could be a charge.
Documentation
Medical records must document that all coverage requirements are met.
12
Cardiovascular Disease Services
Coding and Diagnosis Information
Procedure Codes and Descriptors
Use the following Healthcare Common Procedure Coding System (HCPCS) code to report IBT for
cardiovascular disease.
Table 5. HCPCS Code for IBT for Cardiovascular Disease
HCPCS Code
Code Descriptor
G0446
Intensive behavioral therapy to reduce cardiovascular disease risk,
individual, face-to-face, bi-annual, 15 minutes
Diagnosis Requirements
Although you must report a diagnosis code on
the claim, Medicare does not require a specific
ICD-9-CM diagnosis code for IBT for
cardiovascular disease. Contact your local
Medicare Contractor for further guidance.
Coming Soon!
ICD-10-CM/PCS
For more information, visit http://www.cms.gov/
Medicare/Coding/ICD10 on the CMS website.
Billing Requirements
Billing and Coding Requirements When Submitting Professional Claims
When you submit professional claims to carriers or A/B MACs, report the appropriate HCPCS code
and the corresponding ICD-9-CM diagnosis code in the X12 837-P (Professional) electronic claim
format. You must also include POS codes on all professional claims, to indicate where you provided
the service. For more information on POS codes, visit http://www.cms.gov/Medicare/Coding/placeof-service-codes on the CMS website.
NOTE: If you qualify for an exception to the
ASCA requirement, you may use Form
CMS-1500 to submit these claims on
paper. All providers must use Form
CMS-1500, version 08-05, when
submitting paper claims. For more
information on Form CMS-1500, visit
http://www.cms.gov/Medicare/Billing/
ElectronicBillingEDITrans/16_1500.html
on the CMS website.
13
Electronic Claims Requirements
ASCA requires providers to submit claims to
Medicare electronically, with limited exceptions. For
more information about the electronic formats, visit
http://www.cms.gov/Medicare/Billing/Electronic
B i l l i n g E D I Tr a n s / H e a l t h C a r e C l a i m s . h t m l
on the CMS website.
Cardiovascular Disease Services
Billing and Coding Requirements When Submitting Institutional Claims
When you submit institutional claims to FIs or A/B MACs, report the appropriate HCPCS code,
revenue code, and the corresponding ICD-9-CM diagnosis code in the X12 837-I (Institutional)
electronic claim format.
NOTE: If an institution qualifies for an exception to the ASCA requirement, it may use Form
CMS-1450 to submit these claims on paper. All providers must use Form CMS-1450
(UB-04) when submitting paper claims. For more information on Form CMS-1450, visit
http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/15_1450.html on the
CMS website.
TOBs for Institutional Claims
The FI or A/B MAC pays for IBT for cardiovascular disease when you submit on the following
TOBs. For further guidance on the appropriate revenue code, contact your local Medicare Contractor.
Table 6. Facility Types and TOBs for IBT for Cardiovascular Disease
Facility Type
TOB
Hospital Outpatient
13X
Rural Health Clinic (RHC)
71X
Federally Qualified Health Center (FQHC)
77X
Critical Access Hospital (CAH)
85X
Additional Billing Instructions for FQHCs and RHCs
The professional component of preventive services is within the scope of covered FQHC or RHC
services. The professional component is a physician’s interpretation of the results of an examination.
For instructions on billing the professional component, visit http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1039.pdf
on the CMS website.
The technical component is services rendered outside the scope of the physician’s interpretation
of the results of an examination. If you perform technical components or services, not within the
scope of covered FQHC or RHC services, in association with professional components, how you
bill depends on whether the FQHC or RHC is independent or provider-based:
► For Provider-Based FQHCs or RHCs: Bill the technical component of the service on the
TOB for the base provider and submit to the FI or A/B MAC in the 837-I format. For more
Copyright © 2011, the American Hospital Association, Chicago, Illinois. Reproduced with permission.
No portion of this publication may be copied without the express written consent of the AHA.
14
Cardiovascular Disease Services
information on billing instructions for provider-based FQHCs or RHCs, visit http://www.
cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/
CMS018912.html on the CMS website and choose the appropriate chapter based on your
facility type.
► For Independent FQHCs or RHCs: Bill the technical component of the service to the
carrier or A/B MAC in the 837-P format. For more information on billing instructions
for independent FQHCs or RHCs, visit http://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/Downloads/clm104c12.pdf and http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c26.pdf on the CMS website.
Payment Information
Professional Claims
Providers Must Use EFT
When you bill your carrier or A/B MAC,
Medicare pays for IBT for cardiovascular disease
under the MPFS.
As with other MPFS services, the nonparticipating provider reduction and limiting
charge provisions apply to all IBT sessions for
cardiovascular disease.
All providers enrolling in the Medicare Program
for the first time, changing existing enrollment data,
or revalidating enrollment must use EFT to get
payments. For more information about EFT, visit
http://www.cms.gov/Medicare/Billing/Electronic
BillingEDITrans/EFT.html on the CMS website.
Institutional Claims
When you bill your FI or A/B MAC, Medicare payment for IBT for cardiovascular disease depends
on the type of facility providing the service. Table 7 lists the type of payment that facilities get.
Table 7. Facility Payment Methods for IBT for Cardiovascular Disease
Facility Type
Basis of Payment
Hospital Outpatient*
Outpatient Prospective Payment System
(OPPS)
RHC
All-Inclusive Payment Rate
FQHC
All-Inclusive Payment Rate
Method I: 101% of reasonable cost for
technical component(s) of services
Method II: 101% of reasonable cost
for technical component(s) of services,
plus 115% of MPFS non-facility rate for
professional component(s) of services
CAH
*Medicare pays Maryland hospitals for inpatient or outpatient services according to the Maryland
State Cost Containment Plan.
15
Cardiovascular Disease Services
Reasons for Claim Denial
Medicare may deny coverage of IBT for
cardiovascular disease in several situations,
including:
► You rendered the service in an inappropriate
place or submitted the claim with an
invalid POS.
Medicare Contractor Contact Information
For carrier, FI, or A/B MAC contact information,
visit http://www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/ProviderCompliance-Interactive-Map on the CMS website.
► The beneficiary got IBT for cardiovascular disease furnished by someone who is not a
qualified primary care physician or other primary care practitioner.
► The beneficiary got a covered IBT for cardiovascular disease session in the last 12 months.
You may find specific payment decision
information on the RA. The RA includes CARCs
and RARCs that provide additional information
on payment adjustments. For the most current
listing of these codes, visit http://www.wpc-edi.
com/reference on the Internet. You can obtain
additional information about claims from your
carrier, FI, or A/B MAC.
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RA Information
For more information about the RA, visit
h t t p : / / w w w. c m s . g o v / M e d i c a r e / B i l l i n g /
ElectronicBillingEDITrans/Remittance.html
on the CMS website.
Cardiovascular Disease Services
Resources
For more information about cardiovascular disease screening blood tests
and IBT for cardiovascular disease, refer to the resources listed in Tables 8
and 9. For educational products for Medicare Fee-For-Service health care
professionals and their staff, information on coverage, coding, billing, payment,
and claim filing procedures, visit http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html on
the CMS website, or scan the Quick Response (QR) code to the right with your mobile device.
Table 8. Provider Resources
Resource
Website
CDC Division for Heart Disease
and Stroke Prevention
http://www.cdc.gov/dhdsp
CDC Heart Disease Guidelines
and Recommendations
http://www.cdc.gov/heartdisease/guidelines_
recommendations.htm
CMS Beneficiary Notices
Initiative (BNI)
http://www.cms.gov/Medicare/Medicare-GeneralInformation/BNI
“CMS Electronic Mailing Lists:
http://www.cms.gov/Outreach-and-Education/MedicareKeeping Medicare Fee-For-Service Learning-Network-MLN/MLNProducts/Downloads/
Providers Informed”
MailingLists_FactSheet.pdf
“Medicare Claims Processing
Manual” – Publication 100-04,
Chapter 18, Section 100
http://www.cms.gov/Regulations-and-Guidance/Guidance/
Manuals/Downloads/clm104c18.pdf
Medicare Learning Network
http://www.cms.gov/Outreach-and-Education/Medicare(MLN) Matters® Article MM7636,
Learning-Network-MLN/MLNMattersArticles/
“Intensive Behavioral Therapy (IBT)
Downloads/MM7636.pdf
for Cardiovascular Disease (CVD)”
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Cardiovascular Disease Services
Table 8. Provider Resources (cont.)
Resource
Website
Medicare Preventive Services
General Information
http://www.cms.gov/Medicare/Prevention/
PrevntionGenInfo
Million Hearts (TM)
http://millionhearts.hhs.gov
“Million Hearts: Strategies to
Reduce the Prevalence of
Leading Cardiovascular
Disease Risk Factors”
http://www.cdc.gov/mmwr/preview/mmwrhtml/
mm6036a4.htm
MLN Guided Pathways to
Medicare Resources
The MLN Educational Web Guides MLN Guided
Pathways to Medicare Resources help providers gain
knowledge on resources and products related to Medicare
and the CMS website. For more information about
preventive services, refer to the “Coverage of Preventive
Services” section in the “MLN Guided Pathways to
Medicare Resources – Basic Curriculum for Health
Care Professionals, Suppliers, and Providers” booklet at
http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNEdWebGuide/Downloads/
Guided_Pathways_Basic_Booklet.pdf on the
CMS website.
For all other “Guided Pathways” resources, visit
http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNEdWebGuide/Guided_
Pathways.html on the CMS website.
MLN Matters® Articles
Related to Medicare-covered
Preventive Benefits
http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/
MLNPrevArticles.pdf
MPFS
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched
OPPS
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS
USPSTF Aspirin for the
Prevention of Cardiovascular
Disease Recommendations
For a summary of the USPSTF written recommendations
on aspirin for the prevention of cardiovascular disease,
visit http://www.uspreventiveservicestaskforce.org/uspstf/
uspsasmi.htm on the Internet.
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Cardiovascular Disease Services
Table 8. Provider Resources (cont.)
Resource
Website
USPSTF Behavioral Counseling
in Primary Care to Promote a
Healthy Diet in Adults at
Increased Risk for Cardiovascular
Disease Recommendations
For a summary of the USPSTF written recommendations
on counseling for a healthy diet, visit http://www.
uspreventiveservicestaskforce.org/uspstf/uspsdiet.htm on
the Internet.
USPSTF Screening for High
Blood Pressure in Adults
Recommendations
For a summary of the USPSTF written recommendations
on screening for high blood pressure in adults, visit
http://www.uspreventiveservicestaskforce.org/uspstf/
uspshype.htm on the Internet.
USPSTF Screening
for Lipid Disorders in
Adults Recommendations
For a summary of the USPSTF written recommendations
on screening for lipid disorders in adults, visit http://www.
uspreventiveservicestaskforce.org/uspstf/uspschol.htm on
the Internet.
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Cardiovascular Disease Services
Table 9. Beneficiary Resources
Resource
Website/Contact Information
“Medicare & You: Stay Healthy
with Medicare’s Preventive
Benefits” Video
http://www.youtube.com/watch?v=mBCF0V4R4A0&fatu
re=relmfu
Medicare Beneficiary Help Line
and Website
Telephone:
Toll-Free: 1-800-MEDICARE (1-800-633-4227)
TTY Toll-Free: 1-877-486-2048
Website: http://www.medicare.gov
“Million Hearts Initiative” Video
http://www.youtube.com/watch?v=hjMfwA4ToVE&featu
re=plcp
“Publications for
Medicare Beneficiaries”
http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/
BenePubFS-ICN905183.pdf
Your Medicare Coverage:
Cardiovascular Disease Screenings
http://www.medicare.gov/coverage/cardiovasculardisease-screenings.html
Your Medicare Coverage:
Preventive & Screening Services
http://www.medicare.gov/coverage/preventive-andscreening-services.html
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Official CMS Information for
Medicare Fee-For-Service Providers
The Medicare Learning Network® (MLN), a registered trademark of CMS, is the brand name for official CMS
educational products and information for Medicare Fee-For-Service Providers. For additional information,
visit the MLN’s web page at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNGenInfo on the CMS website.
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