Eight Requirements Satisfy Medicare Blood Test Screening Benefit
By G. John Verhovshek, MA, CP
The Centers for Medicare & Medicaid Services (CMS) will reimburse providers for screening cardiovascular blood tests, but only for those beneficiaries and services meeting strictly-defined requirements, and only for those claims documented and coded appropriately.
Screening blood tests determine a patient’s cholesterol and other blood lipid levels, and may indicate whether he or she is at high risk for cardiovascular disease. Citing the risks and health care costs associated with heart disease, Congress established the cardiovascular blood test screening benefit as part of the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003. Coverage is provided as a Medicare Part B benefit. The beneficiary pays nothing for the blood test; there is no coinsurance, copayment, or deductible.
To meet benefit requirements under the MMA, all of the following conditions must be met:
The screening must be “for the purpose of early detection of cardiovascular disease,” according to the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals .
The patient must be asymptomatic. The beneficiary “must have no apparent signs or symptoms of cardiovascular disease,” the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals explains.
Although the patient must have no apparent signs or symptoms of cardiovascular disease to qualify for the screening, he or she may exhibit one or more risk factors for cardiovascular disease, such as:
- Family history of cardiovascular disease
- High-fat diet
- History of previous heart disease
- Hypercholesterolemia (high cholesterol)
- Lack of exercise
The screening may take place no more often than once every five years (more precisely, at least 59 months after the last covered screening tests). To stress this point, the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals offers two examples of when Medicare may deny coverage of cardiovascular screening blood tests:
- The beneficiary received a covered Lipid Panel during the past 5 years.
- The beneficiary received the same individual cardiovascular screening blood test during the past five years.
The documentation must show that the screening tests were ordered by a physician or non-physician practitioner (NPP). Under CMS guidelines as they pertain to these screenings, a physician is defined as “a doctor of medicine or osteopathy,” while a qualified NPP is defined as “a physician assistant, nurse practitioner, or clinical nurse specialist.”
The beneficiary must fast for 12 hours prior to the test. This is required because the foods we eat and drink can affect the values obtained.
An appropriate HCPCS/CPT® procedure code must be reported.
Cardiovascular screening blood tests covered under the benefit include:
- total cholesterol test (82465 Cholesterol, serum or whole blood, total)
- cholesterol test for high-density lipoproteins (83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol))
- triglycerides test (84478 Triglycerides)
- All other cardiovascular screening blood tests are non-covered, stresses the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals.
Although any of these three tests may be ordered separately, more commonly they are ordered at the same time as part of a full lipid panel (80061 Lipid panel). Note that 80061 bundles 82465, 83718, and 84478; the individual tests are not reported in addition to 80061.
Under CMS guidelines, “laboratories must offer the ability to order a lipid panel without the low-density lipoprotein (LDL) measurement.” If the screening lipid panel shows results that require a further direct LDL measurement, the physician may order the test to arrive at a diagnosis and treatment plan.
Be aware also the five-year frequency limit, mentioned earlier, applies for each test regardless of whether the physician ordered the tests individually or in a panel.
An appropriate diagnosis code must be reported.
A screening diagnosis “V” code should be linked to the claim. ICD-9-CM codes specifically covered under the Medicare screening benefit for cardiovascular blood tests include:
V81.0 Special screening for ischemic heart disease
V81.1 Special screening for hypertension
V81.2 Special screening for other and unspecified cardiovascular conditions
You may report more than a single V code, but always list the primary reason for the screening first. Because patients obtaining the screening are by definition asymptomatic, physicians must indicate in the medical record the primary reason for the test(s).
Individual payers may accept diagnoses not listed above. For example, some payers may accept diabetes (250.x) as a covered diagnosis under the benefit. Check with your payer(s) for details.
All of the above requirements must be documented in the medical record.
Always remember: You can’t code or bill what hasn’t been documented.
When in doubt, consider an ABN
Occasionally, a patient may request or agree to a screening that does not meet the aforementioned requirements. For instance, the service may exceed frequency limitations as defined by the screening benefit (for example, two screenings within a five-year period). In such a case, the provider should ask the patient to sign an Advance Beneficiary Notice (ABN) to ensure reimbursement.
Under CMS rules, as explained in the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Healthcare Professionals:
If the item or service meets the definition of the Medicare-covered benefit, Medicare still may not pay for the item or service if the item or service was “not reasonable and necessary” for the beneficiary on the occasion in question or if the item or service exceeds the frequency limitation for the particular benefit or falls outside the applicable time frame for receipt of the covered benefit.
In these instances, an ABN may be used to shift liability for the cost of the item or service to the beneficiary.
If an ABN is not issued properly in such a case, the provider may be held liable for the cost of the screening unless the provider “is able to demonstrate that they did not know and could not reasonably have been expected to know that Medicare would not pay for the item or service.”
For more information on the ABN and its proper use, visit the CMS website..
G. John Verhovshek, MA, CPC, is AAPC’s director of editorial development–education.