Screening Pelvic Examinations

Screening Pelvic Examinations - Includes a clinical breast examination

HCPCS/CPT Codes

• G0101 – Cervical or vaginal cancer screening; pelvic and clinical breast examination

Covered ICD Codes for CPT G0101

The specified below ICD codes are covered for CPT G0472 and may not be limited and some private payers have own specific guidelines,

High risk 

• Z72.51 - High risk heterosexual behavior
• Z72.52 - High risk homosexual behavior
• Z72.53 - High risk bisexual behavior
• Z72.89 - Other problems related to lifestyle
• Z77.22 - Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)
• Z77.9 - Other contact with and (suspected) exposures hazardous to health
• Z91.89 - Other specified personal risk factors, not elsewhere classified

Low risk

• Z01.411- Encounter for gynecological examination (general) (routine) with abnormal findings
• Z01.419 - Encounter for gynecological examination (general) (routine) without abnormal findings
• Z12.4 - Encounter for screening for malignant neoplasm of cervix
• Z12.72 - Encounter for screening for malignant neoplasm of vagina
• Z12.79 - Encounter for screening for malignant neoplasm of other genitourinary organs
• Z12.89 - Encounter for screening for malignant neoplasm of other sites

Who Is Covered

• All female Medicare beneficiaries

Frequency

• Annually if at high risk for developing cervical or vaginal cancer or childbearing age with abnormal Pap test within past 3 years
• Every 2 years for women at normal risk

Medicare Beneficiary Pays

• Co-payment/coinsurance waived
• Deductible waived

COVID-19 PHE Extension & Flu & Pneumococcal Vaccines Updates for September 2021

Flu & Pneumococcal Vaccines Updates for September 2021

Flu & Pneumococcal Vaccines are Expanded SNF Enforcement Discretion for Certain Pharmacy Billing effective from 09/20/2021.

CMS exercised enforcement discretion for Skilled Nursing Facility (SNF) consolidated billing provisions related to flu and pneumococcal vaccines. 

This allows Medicare-enrolled immunizers, including pharmacies, to bill directly and get direct reimbursement from the Medicare program (including vaccine administration and product), whether these vaccines are administered at the same time (co-administered) with a COVID-19 vaccine or at different times. 

COVID-19 National Public Health Emergency Extension

The U.S. Department of Health and Human Services has extended the COVID-19 national public health emergency by another 90 days. 

And it was scheduled to end Oct. 17, 2021 and now it has been scheduled through Jan. 15, 2022.

The extension is applicable for following services,

• Cost share waivers – Testing
• Cost share waivers – Treatment
• Cost share waivers – Transportation
• Cost share waivers – Medicare Advantage Professional Services
• Telehealth cost share – COVID-19
• Telehealth cost share – Non-COVID-19
• Telehealth expansion
• Timely filing and prescription refills
• Referrals and provisional credentialing
• Prior authorization

Hepatitis B Virus (HBV) Vaccine and Administration

HCPCS/CPT Codes

• 90739 – Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
• 90740 – Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
• 90743 – Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
• 90744 – Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
• 90746 – Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
• 90747 – Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
• G0010 – Administration of Hepatitis B vaccine

Covered ICD-10 Codes for CPT 90739, 90740, 90743, 90744, 90746, 90747

The specified below ICD codes are covered for CPT G0472 and may not be limited and some private payers have own specific guidelines,

• Z23         Encounter for immunization
• R74.01 Elevation of levels of liver transaminase levels
• Z71.84 Encounter for health counseling related to travel

Covered ICD-10 Codes for CPT G0010

The specified below ICD codes are covered for CPT G0472 and may not be limited and some private payers have own specific guidelines,

• B16.0 Acute hepatitis B with delta-agent with hepatic coma
• B16.1 Acute hepatitis B with delta-agent without hepatic coma
• B16.2 Acute hepatitis B without delta-agent with hepatic coma
• B16.9 Acute hepatitis B without delta-agent and without hepatic coma
• B17.0 Acute delta-(super) infection of hepatitis B carrier
• B17.8 Other specified acute viral hepatitis
• B17.9 Acute viral hepatitis, unspecified
• B18.0 Chronic viral hepatitis B with delta-agent
• B18.1 Chronic viral hepatitis B without delta-agent
• B18.8 Other chronic viral hepatitis
• B18.9 Chronic viral hepatitis, unspecified
• B19.10 Unspecified viral hepatitis B without hepatic coma
• B19.11 Unspecified viral hepatitis B with hepatic coma
• K73.9 Chronic hepatitis, unspecified
• K75.2 Nonspecific reactive hepatitis
• Z28.04 Immunization not carried out because of patient allergy to vaccine or component
• Z88.7 Allergy status to serum and vaccine

Who Is Covered

• Certain Medicare beneficiaries at intermediate or high risk for contracting hepatitis B

NOTE: 

Medicare beneficiaries who are currently positive for antibodies for hepatitis B are not eligible for this benefit

Frequency

• Scheduled dosages required

Medicare Beneficiary Pays

• Co-payment/coinsurance waived
• Deductible waived

COVID-19 Vaccine CPT Updates for September and October 2021

Third Dose of Moderna COVID-19 vaccine CPT code has been released,

0013A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose

Other administration codes are, 

0011A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose

0012A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose

Vaccine CPT Code

91301- Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use

October '2021 

Accepted three Category I codes to report SARS-CoV-2 vaccine and immunization administration codes. 

Codes 91307, 0071A, and 0072A are used to report Pfizer COVID-19 vaccine and immunization administration for the tris-sucrose pediatric for patient age 5 through 11 years.

These codes were published on Oct. 6, 2021 and will be effective upon receiving Emergency Use Authorization or approval from the Food and Drug Administration.

September '2021

Accepted eight Category I codes to report SARS-CoV-2 vaccine and immunization administration codes. 

Codes 91305, 0051A, 0052A and 0053A are used to report Pfizer COVID-19 vaccine and immunization administration for the tris-sucrose formulation. 

Codes 0004A and 0054A are used to report Pfizer COVID-19 immunization administration booster doses for both available formulations. 

Codes 91306 and 0064A are used to report Moderna COVID-19 vaccine and immunization administration booster doses. 

Appendix Q has been updated to reflect these additions. These codes were published on Sept. 3, 2021 and will be effective upon receiving Emergency Use Authorization or approval from the Food and Drug Administration.

Hepatitis C Virus (HCV) Screening

HCPCS/CPT Codes

• G0472 – Hepatitis C antibody screening, for individual at high risk and other covered indication(s)

Covered ICD-10 Codes

The specified below ICD codes are covered for CPT G0472 and may not be limited and some private payers have own specific guidelines,

• B17.10 Acute hepatitis C without hepatic coma
• B17.11 Acute hepatitis C with hepatic coma
• B18.2 Chronic viral hepatitis C
• B18.8 Other chronic viral hepatitis
• B18.9 Chronic viral hepatitis, unspecified
• B19.20 Unspecified viral hepatitis C without hepatic coma
• B19.21 Unspecified viral hepatitis C with hepatic coma
• B19.9 Unspecified viral hepatitis without hepatic coma
• B25.1 Cytomegaloviral hepatitis
• F19.20 Other psychoactive substance dependence, uncomplicated
• O98.411 Viral hepatitis complicating pregnancy, first trimester
• O98.412 Viral hepatitis complicating pregnancy, second trimester
• O98.413 Viral hepatitis complicating pregnancy, third trimester
• O98.419 Viral hepatitis complicating pregnancy, unspecified trimester
• O98.42 Viral hepatitis complicating childbirth
• O98.43 Viral hepatitis complicating the puerperium
• Z72.51 High risk heterosexual behavior
• Z72.52 High risk homosexual behavior
• Z72.53 High risk bisexual behavior
• Z72.89 Other problems related to lifestyle

Who Is Covered

Certain adult Medicare beneficiaries who fall into at least one of the following categories,

• High risk for HCV infection
• Born between 1945 and 1965

Frequency

• Annually only for high risk Medicare beneficiaries with continued illicit injection drug use since the prior negative screening test
• Once in a lifetime for Medicare beneficiaries born between 1945 and 1965 who are not considered high risk

Medicare Beneficiary Pays

• Co-payment/coinsurance waived
• Deductible waived

Annual Wellness Visit (AWV) - Medicare

 HCPCS/CPT Codes

• G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit
• G0439 – Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit

Who Is Covered

All Medicare beneficiaries who are both,

• Not within 12 months after the effective date of their first Medicare Part B coverage period
• Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months

Frequently Used ICD

• Z00.00 - Encounter for general adult medical examination without abnormal findings
• Z00.01 - Encounter for general adult medical examination with abnormal findings
• Z00.121 - Encounter for routine child health examination with abnormal findings
• Z00.129 - Encounter for routine child health examination without abnormal findings

Frequency

• Once in a lifetime for G0438 (first AWV)
• Annually for G0439 (subsequent AWV)

Medicare Beneficiary Pays

• Co-payment/Coinsurance waived
• Deductible waived

CMS Will Pay for COVID-19 Booster Shots

Coverage without cost-sharing available for eligible people with Medicare, Medicaid, CHIP, and Most Commercial Health Insurance Coverage

Following the FDA recent action that authorized a booster dose of the Pfizer COVID-19 vaccine for certain high-risk populations and a recommendation from the CDC, CMS will continue to provide coverage for this critical protection from the virus, including booster doses, without cost sharing.

Beneficiaries with Medicare pay nothing for COVID-19 vaccines or their administration, and there is no applicable co-payment, coinsurance, or deductible. 

In addition, thanks to the American Rescue Plan Act of 2021, nearly all Medicaid and CHIP beneficiaries must receive coverage of COVID-19 vaccines and their administration, without cost-sharing. COVID-19 vaccines and their administration, including boosters, will also be covered without cost-sharing for eligible consumers of most issuers of health insurance in the commercial market. 

CMS continues to explore ways to ensure maximum access to COVID-19 vaccinations