More Medicare Payment Updates for 2015

Want to find out more about the Medicare Physician Compare website? The Centers for Medicare & Medicaid Services (CMS) will host a Virtual Office Hour session Thursday, Jan. 22, 10:30-11:30 am CT.

Register for the session by emailing your name, organization, telephone number, and email address to PhysicianCompare[at]Westat[dot]com. Use the subject line "Physician Compare Virtual Office Hour." 

Phase 3 revalidation hot tip: Although the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) instructs you to send hardcopy certification statements/supporting documentation to a specific Novitas address, Novitas requests that you mail all Phase 3 revalidation documents to this address:

Novitas JH Provider Enrollment
PO Box 44137
Jacksonville, FL 32231

Payment Updates

The following Medicare payment changes are effective Jan. 1, 2015, unless otherwise noted.

Pneumococcal vaccine coverage: CMS has updated Medicare coverage of pneumococcal vaccine to align with current Advisory Committee on Immunization Practices (ACIP) recommendations. As of Sept. 19, 2014, Medicare covers:

  • An initial pneumococcal vaccine to all Medicare patients who have never received the vaccine under Medicare Part B; and
  • A different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months have passed following the month in which the last pneumococcal vaccine was administered).

 Because the ACIP recommendations are specific to vaccine type and sequence of vaccination, you'll need to take the patient's pneumococcal vaccination history into consideration. For example, if a patient received the 23-valent pneumococcal polysaccharide vaccine (PPSV23) a year or more ago, then you should administer the 13-valent pneumococcal conjugate vaccine (PCV13) next as the second in the series of the two recommended pneumococcal vaccinations.

Specific modifiers for distinct procedural services: CMS is establishing four new modifiers (XE, XP, XS, and XU) to define subsets of modifier 59, the distinct procedural service modifier. At this time, use of the new modifiers is optional. See CMS' MLN Matters No. MM8863 (PDF). 

Preventive and screening services; see MLN Matters No. MM8874 (PDF):

  • Intensive behavioral therapy for obesity — CMS created code HCPCS G0473 for face-to-face behavioral counseling for obesity, group (2-10), 30 minutes. See National Coverage Determination Chapter 1, Section 210, for coverage requirements. The new code carries the same diagnosis, rendering specialty, place-of-service, and frequency requirements as code G0447 (face-to-face behavioral counseling for obesity, single patient). Only 22 sessions of obesity counseling are billable in a 12-month period; G0473 and G0447 are counted as part of the 22 sessions. Payment is made with one of the ICD-9 codes for body mass index 30.0 and higher: V85.30-V85.39 and V85.41-V85.45.
  • Screening digital tomosynthesis mammography — CMS established new code 77063 for screening breast tomosynthesis. You must report this add-on code with G0202 (screening mammography, digital). Coinsurance and deductible do not apply to code 77063. Payment for 77063 is made only when billed with an ICD-9 code of V76.11 or V76.12.
  • Anesthesia associated with screening colonoscopy — Medicare's definition of "colorectal cancer screening" now includes anesthesia furnished in conjunction with the colorectal cancer screening. Deductible and coinsurance are waived for these anesthesia services when modifier 33 is used. You must report the screening anesthesia under code 00810 (anesthesia for lower intestinal endoscopic procedures) with the 33 modifier (anesthesia complete by total body hypothermia) and perform the service in conjunction with a screening colonoscopy (code G0105 or G0121).

New waived tests: The Food and Drug Administration has approved these tests as waived tests: 81003QW, 86308QW, 87807QW, 87880QW, and G0434QW. CPT codes 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651 do not require a QW modifier to be recognized as a waived test. See MLN Matters No. MM8951 (PDF).

Medicare deductible, coinsurance, and premium rates for 2015: Rates are unchanged from 2014: $104.90 for the standard premium; $147 yearly deductible; 20-percent coinsurance rate. See MLN Matters No. MM8982 (PDF).

TMA's popular annual Medicare update returns! Find out how quality-based payment will affect you. Plus, learn what's on the radar for compliance and audits under Medicare Part B's fraud and abuse work plan. Register now for the seminar, which runs Feb. 3 through Feb. 25 in locations around the state. Also, bookmark the TMA Medicare Resource Center for news and information about Medicare.

Published Jan. 13, 2015

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Last Updated On

December 20, 2016

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