Thanks to the Medicare Modernization Act (MMA), Medicare expanded in January to include three new benefits. Here is what you need to know about each in order to get paid by Medicare.

Welcome to Medicare visit

Section 611 of the MMA provides Medicare coverage for an initial preventive physical examination for new beneficiaries. Only those beneficiaries who begin their Medicare Part B coverage on or after Jan. 1, 2005, and are within six months of the effective date of their coverage are eligible for this benefit. If you have doubts about whether the patient is within the first six months of entitlement to Medicare Part B, you should have the patient sign an Advance Beneficiary Notice indicating that Medicare may not cover the service for that reason.

In general, the initial preventive physical exam includes the following:

• Review of the beneficiary's medical and social history, with attention to modifiable risk factors for disease;

• Review of the beneficiary's potential (risk factors) for depression;

• Review of the beneficiary's functional ability and level of safety;

• An examination to include measurement of the beneficiary's height, weight, blood pressure, visual acuity and other factors as deemed appropriate based on the beneficiary's medical and social history and current clinical standards;

• Performance and interpretation of an electrocardiogram;

• Education, counseling and referral, as appropriate, based on the results of the review and evaluation services described above;

• Education, counseling and referral, including a brief written plan (e.g., checklist), for obtaining the appropriate screening and other preventive services covered as separate benefits under Medicare Part B (influenza vaccine, mammogram, etc.).

You'll need to ensure that your documentation reflects the provision of each of the above elements before billing for the initial preventive physical exam. If you provide the entire service, you'll need to submit two codes:

• G0344, Initial preventive physical examination; face-to-face visit services limited to new beneficiary during the first six months of Medicare enrollments;

• G0366, Electrocardiogram, routine ECG with at least 12 leads with interpretation and report, performed as a component of the initial preventive physical examination.

If you do not have the capacity to perform an ECG in your office, then you will need to make alternative arrangements with an outside entity and incorporate the results into the patient's medical record to complete the initial preventive physical exam. Both the exam and the ECG must be done for either one to be paid, and the Centers for Medicare & Medicaid Services (CMS) plans to issue relevant billing instructions. G0344 will be paid at a rate equal to a level 3, new patient office visit (i.e., $97.40, unadjusted geographically), and G0366 will be paid at a rate equal to a diagnostic ECG (i.e., $27.29).

Note that because the initial preventive physical exam is subject to Medicare's deductible and coinsurance provisions, beneficiaries will typically end up paying most of the Medicare allowed charges (because they will be receiving the services within six months of their enrollment). You may want to alert patients to this fact so it does not come as a surprise when you attempt to collect from them.

Cardiovascular disease screening

Section 612 of the MMA provides for Medicare coverage of cardiovascular (CV) screening blood tests for the early detection of CV disease or abnormalities associated with an elevated risk for that disease. Coverage is provided for three screening blood tests:

• Total cholesterol test,

• Cholesterol test for high-density lipoproteins,

• Triglycerides test.

These three tests should be performed as part of a panel and only following a 12-hour fast. Each of the three tests under this benefit is permitted once every five years. You will use the usual CPT codes when billing for these tests and indicate that they are provided under the cardiovascular screening benefit by connecting the relevant screening diagnosis codes (i.e., V81.0, V81.1, V81.2) to the line item service. Medicare will pay for the three tests under the Medicare Clinical Laboratory Fee Schedule at the rates currently paid for the tests when done diagnostically. While the tests should be performed as a panel, they are also available as individual tests. However, the frequency limit of once every five years for each screening test applies regardless of the ordering pattern. To facilitate claims processing, you must include in the diagnosis section of the claim the ICD-9 code that provides the highest degree of accuracy and completeness in describing the diagnosis.

Diabetes screening tests

Section 613 of the MMA mandates coverage of diabetes screening tests, which the law defines as testing furnished to an individual at risk for diabetes and includes a fasting blood glucose test and other tests. Specifically, CMS is including a fasting blood glucose test and a post-glucose challenge (an oral glucose tolerance test with a glucose challenge of 75 grams for non-pregnant adults or a two-hour post-glucose challenge test alone).

Two screening tests per year are covered for individuals diagnosed with pre-diabetes. CMS defines pre-diabetes as abnormal glucose metabolism diagnosed from a previous fasting glucose level of 100 to 125 mg/dL or a two-hour post-glucose challenge of 140 to 199 mg/dL. The term “pre-diabetes” includes impaired fasting glucose and impaired glucose tolerance. One screening per year is covered for individuals previously tested who were not diagnosed with pre-diabetes or who have never been tested.

Medicare will pay for diabetes screening tests under the Medicare Clinical Laboratory Fee Schedule. You should submit the usual CPT code(s) for the test(s) done and indicate the purpose by using a screening diagnosis code, V77.1, in the diagnosis section of the claim. When the test is performed on individuals diagnosed with pre-diabetes, both the screening diagnosis code V77.1 and a modifier to be determined by CMS are required. (CMS will issue subsequent instructions that provide additional guidance for the billing of diabetes screening for beneficiaries with pre-diabetes.)

Individuals who have any of the following risk factors for diabetes are eligible for this benefit:

• Hypertension,

• Dyslipidemia,

• Obesity (a body mass index equal to or greater than 30 kg/m²),

• Previous identification of elevated impaired fasting glucose or glucose intolerance.

In addition, individuals who have a risk factor consisting of at least two of the following characteristics are eligible for this benefit:

• Overweight (a body mass index greater than 25 but less than 30 kg/m²),

• A family history of diabetes,

• Age 65 years or older,

• A history of gestational diabetes mellitus, or delivering a baby weighing more than 9 pounds.

No coverage is permitted for individuals previously diagnosed with diabetes because these individuals obviously do not require screening.

Positioned for prevention

The new benefits provide an opportunity for physicians to get paid for prevention and screening not previously covered by Medicare. With the information above, you will be in position to make the most of that opportunity.