Alcohol Misuse Screening and Counseling CPT G0442 and G0443

HCPCS/CPT Codes

• G0442 – Annual alcohol misuse screening, 15 minutes
• G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

Who Is Covered

 

All Medicare beneficiaries are eligible for alcohol screening.

 

Medicare beneficiaries who screen positive (those who misuse alcohol but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence) are eligible for counseling if,

• They are competent and alert at the time counseling is provided and
• Counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting

Covered ICD Codes

• F10.282 Alcohol dependence with alcohol-induced sleep disorder
• F10.288 Alcohol dependence with other alcohol-induced disorder
• F10.29 Alcohol dependence with unspecified alcohol-induced disorder
• F10.920 Alcohol use, unspecified with intoxication, uncomplicated
• F10.921 Alcohol use, unspecified with intoxication delirium
• F10.929 Alcohol use, unspecified with intoxication, unspecified
• F10.94 Alcohol use, unspecified with alcohol-induced mood disorder
• F10.950 Alcohol use, unspecified with alcohol-induced psychotic disorder with delusions
• F10.951 Alcohol use, unspecified with alcohol-induced psychotic disorder with hallucinations
• F10.959 Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecified
• F10.96 Alcohol use, unspecified with alcohol-induced persisting amnestic disorder
• F10.97 Alcohol use, unspecified with alcohol-induced persisting dementia
• F10.980 Alcohol use, unspecified with alcohol-induced anxiety disorder
• F10.981 Alcohol use, unspecified with alcohol-induced sexual dysfunction
• F10.982 Alcohol use, unspecified with alcohol-induced sleep disorder
• F10.988 Alcohol use, unspecified with other alcohol-induced disorder
• F10.99 Alcohol use, unspecified with unspecified alcohol-induced disorder
• F12.23 Cannabis dependence with withdrawal
• F12.93 Cannabis use, unspecified with withdrawal
• O99.310 Alcohol use complicating pregnancy, unspecified trimester
• O99.311 Alcohol use complicating pregnancy, first trimester
• O99.312 Alcohol use complicating pregnancy, second trimester
• O99.313 Alcohol use complicating pregnancy, third trimester
• O99.314 Alcohol use complicating childbirth
• O99.315 Alcohol use complicating the puerperium
• R45.88 Nonsuicidal self-harm
• T51.8X2A Toxic effect of other alcohols, intentional self-harm, initial encounter
• T51.8X3A Toxic effect of other alcohols, assault, initial encounter
• T51.8X4A Toxic effect of other alcohols, undetermined, initial encounter
• T51.92XA Toxic effect of unspecified alcohol, intentional self-harm, initial encounter
• T51.93XA Toxic effect of unspecified alcohol, assault, initial encounter
• T51.94XA Toxic effect of unspecified alcohol, undetermined, initial encounter
• Z02.83 Encounter for blood-alcohol and blood-drug test
• Z13.30 Encounter for screening examination for mental health and behavioral disorders, unspecified
• Z13.31 Encounter for screening for depression
• Z13.32 Encounter for screening for maternal depression
• Z13.39 Encounter for screening examination for other mental health and behavioral disorders
• Z63.72 Alcoholism and drug addiction in family
• Z71.41 Alcohol abuse counseling and surveillance of alcoholic
• Z71.42 Counseling for family member of alcoholic
• Z71.84 Encounter for health counseling related to travel
• Z81.1 Family history of alcohol abuse and dependence

Frequency

• Annually for G0442
• For those who screen positive, 4 times per year for G0443

Medicare Beneficiary Pays

• Copayment/coinsurance waived
• Deductible waived

Prostate Cancer Screening CPT G0102 and G0103

HCPCS/CPT Codes

G0102 – Prostate cancer screening; digital rectal examination

• The Physician performs a prostate cancer screening in which he performs a digital rectal examination to assess the male patient’s prostate. 
• To examine the prostate the provider inserts a gloved and lubricated finger into the rectum and checks for hardness, lumps, or any abnormalities. 
• This examination helps detect prostate cancer in its early stages. The provider typically performs this test for the first time at the age of 40 for men at risk of having prostate cancer such as those men with a family history of cancer
• Medicare provides coverage for an annual prostate cancer screening digital rectal examination for men at the age of 50.  

G0103 – Prostate cancer screening; prostate specific antigen test (PSA)

• The Prostate screening examination, the Physician detects the prostate specific antigen, or PSA, level in a patient’s blood. PSA is a protein the prostate gland produces, and he/she may use PSA levels to screen for prostate cancer
• This protein is considered as an indicator for prostate cancer. The Physician collects the blood sample through a venipuncture. This test helps to detect prostate cancer in its early stages. 
• A normal level of PSA in blood level as specified below, 
• For below 50 years of age is less than 2.5
• For age 50 to 60 it is less than 3.5, 
• For age 60 to 70 it is less than 4.5 
• For age above 70 it is 6.6.  
• Medicare provides coverage for an annual prostate cancer screening, or PSA, test for men at the age of 50.

ICD-10 Codes

The specified below ICD codes are covered for CPT G0102 and G0103 but may not be limited and some private payers having specific guidelines.

• D07.5 Carcinoma in situ of prostate
• D29.1 Benign neoplasm of prostate
• D40.0 Neoplasm of uncertain behavior of prostate
• R97.20 Elevated prostate specific antigen [PSA]
• R97.21 Rising PSA following treatment for malignant neoplasm of prostate
• Z12.5 Encounter for screening for malignant neoplasm of prostate
• Z15.03 Genetic susceptibility to malignant neoplasm of prostate
• Z71.84 Encounter for health counseling related to travel
• Z80.42 Family history of malignant neoplasm of prostate
• Z85.46 Personal history of malignant neoplasm of prostate

Who Is Covered

• All male Medicare beneficiaries aged 50 and older (coverage begins the day after their 50th birthday)

Frequency

• Annually for covered Medicare beneficiaries
• Medicare Beneficiary Pays

G0102:

• Co-payment/coinsurance applies
• Deductible applies

G0103:

• Co-payment/coinsurance waived
• Deductible waived

Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests

Human Papillomavirus 

The lab analyst performs the technical steps to detect human papillomavirus through nucleic acid detection and the Nucleic acid probes permit identification of microorganisms based on their DNA or RNA. 

The Nucleic acid quantitation allows assessment of treatment response and the Quantitation refers to measuring the exact amount of a substance. The lab analyst performs this procedure for detection of high risk types of human papillomavirus.

HCPCS/CPT Codes

• G0476 – Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test 

ICD-10 Codes

The specified below ICD codes are covered for CPT G0476 but may not be limited and some private payers having specific guidelines.

• B97.7 Papillomavirus as the cause of diseases classified elsewhere
• R85.81 Anal high risk human papillomavirus (HPV) DNA test positive
• R85.82 Anal low risk human papillomavirus (HPV) DNA test positive
• R87.810 Cervical high risk human papillomavirus (HPV) DNA test positive
• R87.811 Vaginal high risk human papillomavirus (HPV) DNA test positive
• R87.820 Cervical low risk human papillomavirus (HPV) DNA test positive
• R87.821 Vaginal low risk human papillomavirus (HPV) DNA test positive
• Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
• Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
• Z01.42 Encounter for cervical smear to confirm findings of recent normal smear following initial abnormal smear
• Z11.51 Encounter for screening for human papillomavirus (HPV)
• Z86.002 Personal history of in-situ neoplasm of other and unspecified genital organs

Who Is Covered

• All asymptomatic female Medicare beneficiaries aged 30 to 65 years

Frequency

• Once every 5 years

Medicare Beneficiary Pays

• Co-payment/coinsurance waived
• Deductible waived

Intensive Behavioral Therapy (IBT) - CPT G0446

Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)

• Also known as a CVD risk reduction visit

HCPCS/CPT Codes

• G0446 – Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

Covered ICD Codes

The specified below ICD  codes are covered for CPT G0446 but may not be limited and some private payers having specific guidelines.

• F53.0    Postpartum depression
• F53.1    Puerperal psychosis 
• F68.A    Factitious disorder imposed on another
• I01.0 Acute rheumatic pericarditis
• I01.1 Acute rheumatic endocarditis
• I01.2 Acute rheumatic myocarditis
• I01.8 Other acute rheumatic heart disease
• I01.9 Acute rheumatic heart disease, unspecified
• I02.0 Rheumatic chorea with heart involvement
• I02.9 Rheumatic chorea without heart involvement
• I05.0 Rheumatic mitral stenosis
• I05.1 Rheumatic mitral insufficiency
• I05.2 Rheumatic mitral stenosis with insufficiency
• I05.8 Other rheumatic mitral valve diseases
• I05.9 Rheumatic mitral valve disease, unspecified
• I06.0 Rheumatic aortic stenosis
• I06.1 Rheumatic aortic insufficiency
• I06.2 Rheumatic aortic stenosis with insufficiency
• I06.8 Other rheumatic aortic valve diseases
• I06.9 Rheumatic aortic valve disease, unspecified
• I07.0 Rheumatic tricuspid stenosis
• I07.1 Rheumatic tricuspid insufficiency
• I07.2 Rheumatic tricuspid stenosis and insufficiency
• I07.8 Other rheumatic tricuspid valve diseases
• I07.9 Rheumatic tricuspid valve disease, unspecified
• I08.0 Rheumatic disorders of both mitral and aortic valves
• I08.1 Rheumatic disorders of both mitral and tricuspid valves
• I08.2 Rheumatic disorders of both aortic and tricuspid valves
• I08.3 Combined rheumatic disorders of mitral, aortic and tricuspid valves
• I08.8 Other rheumatic multiple valve diseases
• I08.9 Rheumatic multiple valve disease, unspecified
• I09.0 Rheumatic myocarditis
• I09.1 Rheumatic diseases of endocardium, valve unspecified
• I09.2 Chronic rheumatic pericarditis
• I09.81 Rheumatic heart failure
• I09.89 Other specified rheumatic heart diseases
• I09.9 Rheumatic heart disease, unspecified
• I10         Essential (primary) hypertension
• I11.0 Hypertensive heart disease with heart failure
• I11.9 Hypertensive heart disease without heart failure
• I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
• I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
• I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
• I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
• I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
• I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
• I15.0 Reno vascular hypertension
• I15.1 Hypertension secondary to other renal disorders
• I15.2 Hypertension secondary to endocrine disorders
• I15.8 Other secondary hypertension
• I15.9 Secondary hypertension, unspecified
• I16.0 Hypertensive urgency
• I16.1 Hypertensive emergency
• I16.9 Hypertensive crisis, unspecified
• I20.0 Unstable angina
• I20.1 Angina pectoris with documented spasm
• I20.8 Other forms of angina pectoris
• I20.9 Angina pectoris, unspecified
• I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
• I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
• I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
• I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
• I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
• I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
• I21.29 ST elevation (STEMI) myocardial infarction involving other sites
• I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
• I21.4 Non-ST elevation (NSTEMI) myocardial infarction
• I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
• I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
• I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
• I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
• I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
• I23.0 Hemopericardium as current complication following acute myocardial infarction
• I23.1 Atrial septal defect as current complication following acute myocardial infarction
• I23.2 Ventricular septal defect as current complication following acute myocardial infarction
• I23.3 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction
• I23.4 Rupture of chordae tendineae as current complication following acute myocardial infarction
• I23.5 Rupture of papillary muscle as current complication following acute myocardial infarction
• I23.6 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction
• I23.7 Postinfarction angina
• I23.8 Other current complications following acute myocardial infarction
• I24.0 Acute coronary thrombosis not resulting in myocardial infarction
• I24.1 Dressler's syndrome
• I24.8 Other forms of acute ischemic heart disease
• I24.9 Acute ischemic heart disease, unspecified
• I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
• I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
• I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
• I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
• I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
• I25.2 Old myocardial infarction
• I25.3 Aneurysm of heart
• I25.41 Coronary artery aneurysm
• I25.42 Coronary artery dissection
• I25.5 Ischemic cardiomyopathy
• I25.6 Silent myocardial ischemia
• I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
• I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm
• I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris
• I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris
• I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris
• I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm
• I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
• I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris
• I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris
• I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm
• I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris
• I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris
• I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris
• I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm
• I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris
• I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
• I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina
• I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm
• I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris
• I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
• I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina
• I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm
• I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris
• I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
• I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris
• I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm
• I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris
• I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris
• I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
• I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris
• I25.812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris
• I25.82 Chronic total occlusion of coronary artery
• I25.83 Coronary atherosclerosis due to lipid rich plaque
• I25.84 Coronary atherosclerosis due to calcified coronary lesion
• I25.89 Other forms of chronic ischemic heart disease
• I25.9 Chronic ischemic heart disease, unspecified
• I26.01 Septic pulmonary embolism with acute cor pulmonale
• I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
• I26.09 Other pulmonary embolism with acute cor pulmonale
• I26.90 Septic pulmonary embolism without acute cor pulmonale
• I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
• I26.93 Single subsegmental pulmonary embolism without acute cor pulmonale
• I26.94 Multiple subsegmental pulmonary emboli without acute cor pulmonale
• I26.99 Other pulmonary embolism without acute cor pulmonale
• I27.0 Primary pulmonary hypertension
• I27.1 Kyphoscoliotic heart disease
• I27.81 Cor pulmonale (chronic)
• I27.82 Chronic pulmonary embolism
• I27.89 Other specified pulmonary heart diseases
• I27.9 Pulmonary heart disease, unspecified
• I28.0 Arteriovenous fistula of pulmonary vessels
• I28.1 Aneurysm of pulmonary artery
• I28.8 Other diseases of pulmonary vessels
• I28.9 Disease of pulmonary vessels, unspecified
• I30.0 Acute nonspecific idiopathic pericarditis
• I30.1 Infective pericarditis
• I30.8 Other forms of acute pericarditis
• I30.9 Acute pericarditis, unspecified
• I31.0 Chronic adhesive pericarditis
• I31.1 Chronic constrictive pericarditis
• I31.2 Hemopericardium, not elsewhere classified
• I31.3 Pericardial effusion (noninflammatory)
• I31.4 Cardiac tamponade
• I31.8 Other specified diseases of pericardium
• I31.9 Disease of pericardium, unspecified
• I32         Pericarditis in diseases classified elsewhere
• I33.0 Acute and subacute infective endocarditis
• I33.9 Acute and subacute endocarditis, unspecified 
• I34.0 Nonrheumatic mitral (valve) insufficiency
• I34.1 Nonrheumatic mitral (valve) prolapse
• I34.2 Nonrheumatic mitral (valve) stenosis
• I34.8 Other nonrheumatic mitral valve disorders
• I34.9 Nonrheumatic mitral valve disorder, unspecified
• I35.0 Nonrheumatic aortic (valve) stenosis
• I35.1 Nonrheumatic aortic (valve) insufficiency
• I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency
• I35.8 Other nonrheumatic aortic valve disorders
• I35.9 Nonrheumatic aortic valve disorder, unspecified
• I36.0 Nonrheumatic tricuspid (valve) stenosis
• I36.1 Nonrheumatic tricuspid (valve) insufficiency
• I36.2 Nonrheumatic tricuspid (valve) stenosis with insufficiency
• I36.8 Other nonrheumatic tricuspid valve disorders
• I36.9 Nonrheumatic tricuspid valve disorder, unspecified
• I37.0 Nonrheumatic pulmonary valve stenosis
• I37.1 Nonrheumatic pulmonary valve insufficiency
• I37.2 Nonrheumatic pulmonary valve stenosis with insufficiency
• I37.8 Other nonrheumatic pulmonary valve disorders
• I37.9 Nonrheumatic pulmonary valve disorder, unspecified
• I38         Endocarditis, valve unspecified
• I39         Endocarditis and heart valve disorders in diseases classified elsewhere
• I40.0 Infective myocarditis
• I40.1 Isolated myocarditis
• I40.8 Other acute myocarditis
• I40.9 Acute myocarditis, unspecified
• I41         Myocarditis in diseases classified elsewhere
• I42.0 Dilated cardiomyopathy
• I42.1 Obstructive hypertrophic cardiomyopathy
• I42.2 Other hypertrophic cardiomyopathy
• I42.3 Endomyocardial (eosinophilic) disease
• I42.4 Endocardial fibroelastosis
• I42.5 Other restrictive cardiomyopathy
• I42.6 Alcoholic cardiomyopathy
• I42.7 Cardiomyopathy due to drug and external agent
• I42.8 Other cardiomyopathies
• I42.9 Cardiomyopathy, unspecified
• I43         Cardiomyopathy in diseases classified elsewhere
• I44.0 Atrioventricular block, first degree
• I44.1 Atrioventricular block, second degree
• I44.2 Atrioventricular block, complete
• I44.30 Unspecified atrioventricular block
• I44.39 Other atrioventricular block
• I44.4 Left anterior fascicular block
• I44.5 Left posterior fascicular block
• I44.60 Unspecified fascicular block
• I44.69 Other fascicular block
• I44.7 Left bundle-branch block, unspecified
• I45.0 Right fascicular block
• I45.10 Unspecified right bundle-branch block
• I45.19 Other right bundle-branch block
• I45.2 Bifascicular block
• I45.3 Trifascicular block
• I45.4 Nonspecific intraventricular block
• I45.5 Other specified heart block
• I45.6 Pre-excitation syndrome
• I45.81 Long QT syndrome
• I45.89 Other specified conduction disorders
• I45.9 Conduction disorder, unspecified
• I46.2 Cardiac arrest due to underlying cardiac condition
• I46.8 Cardiac arrest due to other underlying condition
• I46.9 Cardiac arrest, cause unspecified
• I47.0 Re-entry ventricular arrhythmia
• I47.1 Supraventricular tachycardia
• I47.2 Ventricular tachycardia
• I47.9 Paroxysmal tachycardia, unspecified
• I48.0 Paroxysmal atrial fibrillation
• I48.11 Longstanding persistent atrial fibrillation
• I48.19 Other persistent atrial fibrillation
• I48.20 Chronic atrial fibrillation, unspecified
• I48.21 Permanent atrial fibrillation
• I48.3 Typical atrial flutter
• I48.4 Atypical atrial flutter
• I48.91 Unspecified atrial fibrillation
• I48.92 Unspecified atrial flutter
• I49.01 Ventricular fibrillation
• I49.02 Ventricular flutter
• I49.1 Atrial premature depolarization
• I49.2 Junctional premature depolarization
• I49.3 Ventricular premature depolarization
• I49.40 Unspecified premature depolarization
• I49.49 Other premature depolarization
• I49.5 Sick sinus syndrome
• I49.8 Other specified cardiac arrhythmias
• I49.9 Cardiac arrhythmia, unspecified
• I50.1 Left ventricular failure, unspecified
• I50.20 Unspecified systolic (congestive) heart failure
• I50.21 Acute systolic (congestive) heart failure
• I50.22 Chronic systolic (congestive) heart failure
• I50.23 Acute on chronic systolic (congestive) heart failure
• I50.30 Unspecified diastolic (congestive) heart failure
• I50.31 Acute diastolic (congestive) heart failure
• I50.32 Chronic diastolic (congestive) heart failure
• I50.33 Acute on chronic diastolic (congestive) heart failure
• I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
• I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
• I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
• I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
• I50.9 Heart failure, unspecified
• I51.0 Cardiac septal defect, acquired
• I51.1 Rupture of chordae tendineae, not elsewhere classified
• I51.2 Rupture of papillary muscle, not elsewhere classified
• I51.3 Intracardiac thrombosis, not elsewhere classified
• I51.4 Myocarditis, unspecified
• I51.5 Myocardial degeneration
• I51.7 Cardiomegaly
• I51.81 Takotsubo syndrome
• I51.89 Other ill-defined heart diseases
• I51.9 Heart disease, unspecified
• I52         Other heart disorders in diseases classified elsewhere
• Z13.30 Encounter for screening examination for mental health and behavioral disorders, unspecified
• Z13.31 Encounter for screening for depression
• Z13.32 Encounter for screening for maternal depression
• Z13.39 Encounter for screening examination for other mental health and behavioral disorders

Who Is Covered

All Medicare beneficiaries covered when following criteria are met,

• Competent and alert at the time counseling is provided
• Furnished counseling by a qualified primary care physician or other primary care practitioner and in a primary care setting

Frequency

• Annually for covered Medicare beneficiaries

Medicare Beneficiary Pays

• Co-payment/coinsurance waived
• Deductible waived

Intensive Behavioral Therapy (IBT) for Obesity

HCPCS/CPT Codes

• G0447 – Face-to-face behavioral counseling for obesity, 15 minutes
• G0473 – Face-to-face behavioral counseling for obesity, group (2–10), 30 minutes

Covered ICD-10 Codes for CPT G0447 & G0473

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

• Z68.30 - Body mass index [BMI] 30.0-30.9, adult
• Z68.31  -Body mass index [BMI] 31.0-31.9, adult
• Z68.32 - Body mass index [BMI] 32.0-32.9, adult
• Z68.33 - Body mass index [BMI] 33.0-33.9, adult
• Z68.34 - Body mass index [BMI] 34.0-34.9, adult
• Z68.35 - Body mass index [BMI] 35.0-35.9, adult
• Z68.36 - Body mass index [BMI] 36.0-36.9, adult
• Z68.37 - Body mass index [BMI] 37.0-37.9, adult
• Z68.38 - Body mass index [BMI] 38.0-38.9, adult
• Z68.39 - Body mass index [BMI] 39.0-39.9, adult
• Z68.41 - Body mass index [BMI] 40.0-44.9, adult
• Z68.42 - Body mass index [BMI] 45.0-49.9, adult
• Z68.43 - Body mass index [BMI] 50.0-59.9, adult
• Z68.44 - Body mass index [BMI] 60.0-69.9, adult
• Z68.45 - Body mass index [BMI] 70 or greater, adult

Require primary ICD Codes for above diagnosis,

• E66.9 - Obesity, unspecified
• E66.8 - Other obesity
• E66.3 - Overweight
• E66.2 - Morbid (severe) obesity with alveolar hypoventilation
• E66.1 - Drug-induced obesity
• E66.09 - Other obesity due to excess calories
• E66.01 - Morbid (severe) obesity due to excess calories

Who Is Covered

The Medicare beneficiaries requires the following information to meat the medical necessity 

• Obesity (Body Mass Index [BMI] ≥ 30 kilograms [kg] per meter squared)
• Competent and alert at the time counseling is provided
• Counseling furnished by a qualified primary care physician or other primary care practitioner in a primary care setting

Frequency

• First month: one face-to-face visit every week
• Months 2–6: one face-to-face visit every other week
• Months 7–12: one face-to-face visit every month if certain requirements are met.

At the 6-month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed.

To be eligible for additional face-to-face visits occurring once a month for an additional 6 months, Medicare beneficiaries must have lost at least 3 kg.

For Medicare beneficiaries who do not achieve a weight loss of at least 3 kg during the first 6 months, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period.

Medicare Beneficiary Pays

• Co-payment/coinsurance waived
• Deductible waived

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

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

Billin Guidelines for Depression Screening

Reimbursement Guidelines for Depression Screening - CPT G0444

Depression screening CPT G0444 can't be coded with CPT G0402 & G0438 but you may report with CPT G0439. NCCI edits stated as "Code G0444 is a column 2 code for G0402. You may not override the edit".

Details of the CPTs,

• G0444 - Annual depression screening, 15 minutes
• G0402 - Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
• G0438 - Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit

Nationally Covered Indications:

CMS will cover annual screening up to 15 minutes for Medicare beneficiaries when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. 

At a minimum level, staff assisted supports consist of clinical staff (e.g., physician assistant, nurse) in the primary care setting who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment. Services covered under this NCD must be provided by a primary care provider.

Nationally Non-Covered Indications:

Screening for depression is non-covered when performed more than one time in a 12-month period. Also self-help materials, telephone calls, and web-based counseling are not separately reimbursable by Medicare and are not part of this NCD.

Medicare coinsurance and Part B deductible are waived for this preventive service.

Covered ICD Codes:

 

The specified below ICD codes are covered for depression screening services and may not be limited and some private payers have specific guidelines,

• F06.0 Psychotic disorder with hallucinations due to known physiological condition
• F06.2 Psychotic disorder with delusions due to known physiological condition
• F06.30 Mood disorder due to known physiological condition, unspecified
• F06.31 Mood disorder due to known physiological condition with depressive features
• F06.32 Mood disorder due to known physiological condition with major depressive-like episode
• F06.33 Mood disorder due to known physiological condition with manic features
• F06.34 Mood disorder due to known physiological condition with mixed features
• F06.4 Anxiety disorder due to known physiological condition
• F06.8 Other specified mental disorders due to known physiological condition
• F07.0 Personality change due to known physiological condition
• F07.89 Other personality and behavioral disorders due to known physiological condition
• F07.9 Unspecified personality and behavioral disorder due to known physiological condition
• F09 Unspecified mental disorder due to known physiological condition
• F32.0 Major depressive disorder, single episode, mild
• F32.1 Major depressive disorder, single episode, moderate
• F32.2 Major depressive disorder, single episode, severe without psychotic features
• F32.3 Major depressive disorder, single episode, severe with psychotic features
• F32.4 Major depressive disorder, single episode, in partial remission
• F32.5 Major depressive disorder, single episode, in full remission
• F32.81 Premenstrual dysphoric disorder
• F32.89 Other specified depressive episodes
• F32.9 Major depressive disorder, single episode, unspecified
• F32.A Depression, unspecified
• F33.0 Major depressive disorder, recurrent, mild
• F33.1 Major depressive disorder, recurrent, moderate
• F33.2 Major depressive disorder, recurrent severe without psychotic features
• F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
• F33.40 Major depressive disorder, recurrent, in remission, unspecified
• F33.41 Major depressive disorder, recurrent, in partial remission
• F33.42 Major depressive disorder, recurrent, in full remission
• F33.8 Other recurrent depressive disorders
• F33.9 Major depressive disorder, recurrent, unspecified
• F43.21 Adjustment disorder with depressed mood
• F43.22 Adjustment disorder with anxiety
• F43.23 Adjustment disorder with mixed anxiety and depressed mood
• F43.24 Adjustment disorder with disturbance of conduct
• F43.25 Adjustment disorder with mixed disturbance of emotions and conduct
• F43.29 Adjustment disorder with other symptoms
• F53.0 Postpartum depression
• F53.1 Puerperal psychosis
• F68.A Factitious disorder imposed on another
• R45.88 Nonsuicidal self-harm
• Z13.31 Encounter for screening for depression
• Z13.32 Encounter for screening for maternal depression
• Z13.39 Encounter for screening examination for other mental health and behavioral disorders
  

 

Place Of Service:

Effective for claims with dates of service on and after April 2, 2012, contractors shall pay for annual depression screening claims, G0444, only when services are provided at the following Places of Service (POS)

• 11 Physician’s office
• 19 Off Campus-Outpatient hospital
• 22 On Campus-Outpatient hospital
• 49 Independent clinic 
• 71 State or local public health clinic