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New Codes for Reimbursement from Medicare for Preventive Services

Feb 21, 2012

You’ve probably heard that Medicare now covers an additional set of preventive services, such as intensive behavioral therapy for cardiovascular disease risk and obesity, and screening for depression. But do you know the rules concerning these services or the G-codes for them?

The Centers for Medicare & Medicaid Services (CMS) has released a quarterly update providing new Healthcare Common Procedure Coding System (HCPCS) codes for January 2012. Often the HCPCS updates don’t have much to offer family physicians, but this group may be worth noting.

You have probably seen the announcements of new Medicare coverage for preventive services such as intensive behavioral therapy for cardiovascular disease risk and obesity, screening for depression, and screening for sexually transmitted infections. What is missing for some of these newly covered services is the guidance on what must be included and documented for the services, the codes used to report them, and the payment amounts for each.

We have put together a table of what we know so far about the codes, who can provide the services and in what settings, and how often each service is covered. There is still a lot we do not know, including when these services will be bundled with other services provided on the same date, but CMS should soon publish that information in the April 2012 National Correct Coding Edits.

Other notable 2012 HCPCS codes include the following:

  • G0449: Annual face-to-face obesity screening, 15 minutes — notable because this new code is listed in the fee schedule as a non-covered service;
  • G0451: Development testing, with interpretation and report per standardized instrument form — notable because this may be required by Medicaid or health plans in lieu of CPT 96110 due to the change in the CPT code descriptor to “Developmental screening, with interpretation and report, per standardized instrument form”;
  • G9156: Evaluation for wheelchair requiring face-to-face visit with physician — notable because this code is used to report services related to a CMS action to correct improper payments for power mobility devices. Medicare contractors in the following states, CA, FL, IL, MI, NY, NC, and TX, began 100 percent prepayment review for initial rental or purchase claims after Jan. 1, 2012 and prior authorization of power mobility devices beginning April 1, 2012. This may be implemented in other states in the future. To compensate physicians for time associated with preparing and submitting a prior authorization request, code G9156 is reported after submission of the initial prior authorization request with the prior authorization tracking number provided by the Medicare durable medical equipment contractor. Claims are submitted to the Medicare Part B contractor and only one claim with code G9156 may be billed per beneficiary per power mobility device even if a physician must resubmit the request for prior authorization. For more information from CMS, see this presentation.

There will likely be more changes to come in 2012, especially to the preventive service benefits as defined by the Affordable Care Act. Here’s hoping the benefits to patients outweigh the complexity of the Medicare benefit structure.

Codes and More Information