Cardiovascular Disease Services DEPARTMENT OF HEALTH AND HUMAN SERVICES
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. 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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. 16 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)” 17 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. 18 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. 19 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 20 This page intentionally left blank. R 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. 22
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