Apr 1998 Table of Contents

REIMBURSEMENT STRATEGIES

MEDICARE UPDATE

An Ounce of Prevention



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Fam Pract Manag. 1998 Apr;5(4):10-12.

They say that an ounce of prevention is worth a pound of cure. Unfortunately, federal law — and Medicare, by extension — has not put much stock in the old adage. However, the Balanced Budget Act of 1997 (BBA) has begun to remedy that. The new law liberalizes coverage for some of the clinical preventive services Medicare covers and expands coverage to include several other services. Many of the changes took effect Jan. 1, 1998. Here's a summary:

Screening mammography

BBA simplified and expanded the existing Medicare coverage of screening mammograms. Effective Jan. 1, 1998, Medicare covers an annual screening mammogram for all women over age 39. Furthermore, the Medicare deductible does not apply. Continue using the existing CPT code for this service.

Screening Pap smears and pelvic exams

Effective Jan. 1, 1998, Medicare covers screening pelvic exams (including a clinical breast exam) for all female beneficiaries, with some limitations. Specifically, the law allows payment for one screening pelvic exam every three years, but Medicare may pay for one annually if the beneficiary falls into one of the following categories:

  1. Is of childbearing age and has had an exam indicating the presence of cervical or vaginal cancer or other abnormality during any of the preceding three years;

  2. Is considered to be at high risk for vaginal cancer as evidenced by prenatal exposure to diethylstilbestrol or for cervical cancer as evidenced by any of the following:

    • Early onset of sexual activity (under 16 years of age),

    • Multiple sexual partners (five or more in a lifetime),

    • History of a sexually transmitted disease (including HIV),

    • Absence of three negative Pap smears or complete absence of Pap smears within the previous seven years.

Again, the Medicare deductible does not apply to this service. Submit HCPCS code G0101.

Colorectal screening

The following colorectal screening tests are covered under Medicare effective Jan. 1, 1998:

  • Annual screening fecal-occult blood tests for beneficiaries 50 years or older (use HCPCS code G0107),

  • Screening flexible sigmoidoscopy every four years for beneficiaries 50 years or older (use HCPCS code G0104),

  • Screening colonoscopy for beneficiaries with high risk (e.g., those with family history of cancer or previous cancer illness) every two years (use HCPCS code G0105).

Medicare will reimburse for these screening tests at the same rate as their diagnostic equivalents.

In addition, Medicare now covers a screening barium enema as a substitute for either a screening sigmoidoscopy or a screening colonoscopy under the same conditions applied to those two tests. Use HCPCS code G0106 when a screening barium enema is substituted for a screening sigmoidoscopy and G0120 when a screening barium enema is substituted for a screening colonoscopy. Reimbursement for the screening barium enema will equal reimbursement for a diagnostic barium enema. Finally, note that Medicare considers the double-contrast barium enema to be the standard, but in the case of some patients who are infirm, immobile or debilitated, Medicare will cover the single contrast test.

Diabetes self-management

Under BBA, Medicare also covers diabetes self-management education and training when furnished to an individual with diabetes by a certified provider in an outpatient setting. This change will take effect July 1, 1998. Medicare has yet to work out many of the details regarding this provision, such as coding, payment levels and the definition of “certified provider.” However, coverage will require certification that the services are needed under a comprehensive plan of care to ensure therapy compliance or to provide the patient with diabetes self-management skills and knowledge. The physician managing the patient's diabetic condition is responsible for providing the certification.

Also beginning on July 1, Medicare will cover blood-glucose monitors and blood-testing strips without regard to whether the Medicare beneficiary has type I or type II diabetes or whether he or she uses insulin. Currently, Medicare limits coverage to beneficiaries with type I, insulin-treated diabetes.

Prostate cancer screening tests

Finally, looking quite a way into the future, effective Jan. 1, 2000, BBA provides for Medicare coverage of annual prostate cancer screening tests for men over age 50. Such tests may include a digital rectal exam and a prostate-specific antigen blood test.

A good start

Medicare still does not cover a list of clinical preventive services that family physicians would advocate for their patients. However, thanks to BBA, that list is shorter in 1998.

Kent Moore is the AAFP's manager for reimbursement issues and a contributing editor to Family Practice Management.

Copyright © 1998 by the American Academy of Family Physicians.
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