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in section 5112 of the Deficit Reduction Act (DRA) of Effective 5-'#)%'B+8%)#5&'"+)3%:#-"#-'#$52%'#E$"&$'(#F9#GAAH9#7%:+8$'%#4+..#?$(#5-'# $#-"%I2+*%#-".(#?'%B%"2+B%#&.2'$)-&":#)8'%%"+"/#5-'#23%#%$'.(#:%2%82+-"# of AAAs for at-risk beneficiaries, resulting from a referral from an Initial Preventive Physical Examination (IPPE).!"#$%&'()*+,-$..)/)0+1'$+23*'4/)%"+2'$#/-+2).($5&4& 9:;6<=2>=+>6=? Only Medicare beneficiaries who '%8%+B%#$#'%5%''$.#5-'#23%#!!!# &.2'$)-&":#)8'%%"+"/#$)#$#'%)&.2# of the IPPE will be covered for the AAA benefit. The term ultrasound screening for abdominal aortic aneurysm is defined as the accuracy and cost, as specified by CMS through the national coverage determination process)?'-b+:%:#5-'#23%#%$'.(#:%2%82+-"#-5#!!!j#$": BA+ K"8.&:%)#$#?3()+8+$"D)#+"2%'?'%2$2+-"#-5#23%#'%)&.2)#-5#23%#?'-8%:&'%6 </&C+D%-#'$& An AAA can develop in anyone; however, risk factors for developing an AAA include the following: 7$.%#/%":%'!/%#LM#-'#-.:%' N+)2-'(#-5#%B%'#)*-O+"/#;$2#.%$)2#FAA#8+/$'%22%)#+"#$#?%')-"D)#.+5%2+*%< P$*+.(#3+)2-'(#-5#!!!) Coronary heart disease N(?%'83-.%)2%'-.%*+$ N(?%'2%")+-" Cerebrovascular disease EE

2 F'7.$%0.+9)1'$4%#/')!"#$%&'(#$!)$*#('+,-#$.-#/#0!'/#$1#-/'+#1$ 7%:+8$'%#?'-B+:%)#8-B%'$/%#-5#$#-"%I2+*%#?'%B%"2+B%#&.2'$)-&":#)8'%%"+"/#5-'#23%#%$'.(#:%2%82+-"#-5#$"# AAA for eligible beneficiaries who meet the following criteria: The beneficiary receives a referral for an ultrasound screening as a result of an IPPE; The beneficiary receives a referral from a provider or supplier who is authorized to provide covered &.2'$)-&":#:+$/"-)2+8#)%'B+8%)J The beneficiary has not been previously furnished an ultrasound screening under the Medicare Q'-/'$*J#$": The beneficiary is included in at least '). of the following risk categories: The beneficiary has a family history of AAAs; The beneficiary is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or The beneficiary manifests other risk factors in a beneficiary category recommended for ultrasound screening by the United States Preventive Services Task Force (USPSTF) regarding AAAs, as specified by the Secretary of Health and Human Services through the national coverage :%2%'*+"$2+-"#?'-8%))6 7%:+8$'%#?'-B+:%)#8-B%'$/%#5-'#23%#&.2'$)-&":#)8'%%"+"/#5-'#!!!#$)#$#7%:+8$'%#Q$'2#R#,%"%5+26#=3%# coinsurance or copayment applies. There is no Medicare Part B deductible for this benefit. G'-(4.)#%#/') 7%:+8$.#'%8-':#:-8&*%"2$2+-"#*&)2#)3-4#23$2#23%#&.2'$)-&":#)8'%%"+"/#4$)#-':%'%:#,(#$#?3()+8+$"#-'# qualified non-physician practitioner treating an asymptomatic beneficiary for the purpose of early detection of an AAA as a result of the IPPE. The Medicare provider should document the appropriate supporting?'-8%:&'%#$":#:+$/"-)+)#8-:%)6 F'*/)0+%)*+G/%0)'&/&+9)1'$4%#/') ;$'-.*($.+F'*.&+%)*+G.&-$/H#'$& The following Healthcare Common Procedure Coding System (HCPCS) code listed in Table 1 is used to report the AAA ultrasound screening service: =%3".+@+I+JF;F,+F'*.+1'$+222+!"#$%&'()*+,-$..)/)0+,.$7/-.+ JF;F,+F'*. SA@TU F'*.+G.&-$/H#'$ C.2'$)-&":9#RI)8$"#$":V-'#'%$.#2+*%#4+23#+*$/%#:-8&*%"2$2+-"J#5-'#$,:-*+"$.# $-'2+8#$"%&'()*#;!!!<#&.2'$)-&":#)8'%%"+"/ G/%0)'&/&+<.K(/$.4.)#& Although Medicare providers must report a diagnosis code on the claim, there are no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes that are required for the AAA ultrasound screening. Providers should choose an appropriate ICD-9-CM diagnosis code. Contact the local Medicare Contractor for further guidance. 67$ &5!-,1)&0($1+-##0'0%$2)-$,8()*'0,5$,)-!'+$,0#&-31*1

3 L/""/)0+<.K(/$.4.)#& L/""/)0+%)*+F'*/)0+<.K(/$.4.)#&+MN.)+,(34/##/)0+F"%/4&+#'+F%$$/.$&O2L+:.*/-%$.+ 2*4/)/&#$%#/7.+F')#$%-#'$&+P2L+:2F&Q W3%"#?3()+8+$")# $":# X&$.+5+%:# "-"I?3()+8+$"#?'$82+2+-"%')#$'%#)&,*+22+"/#8.$+*)#2-#8$''+%')V!R# MACs, they must report HCPCS code G0389 and Q'-5%))+-"$.#%.%82'-"+8#8.$+*#5-'*$26# >6=?R+ In those cases where a supplier qualifies for an exception to the ASCA requirement, Form CMS-1500 may be used to submit these claims on paper. Form CMS-1500 has been revised 2-#$88-**-:$2%#23%#'%?-'2+"/#-5#23%#Y$2+-"$.# Provider Identifier (NPI). All providers must use Form CMS-1500 (08-05) when submitting?$?%'#8.$+*)6#!::+2+-"$.#+"5-'*$2+-"#-"#p-'*# CMS-1500 can be found at hhs.gov/electronicbillingeditrans/16_1500. $)? on the CMS website. Administrative Simplification Compliance 2-#+F"%/4&+<.K(/$.4.)#& The Administrative Simplification Compliance Act (ASCA) requires that claims be submitted to 7%:+8$'%#%.%82'-"+8$..(#2-#,%#8-")+:%'%:#5-'#?$(*%"2# with limited exceptions. Claims are to be submitted %.%82'-"+8$..(#&)+"/#23%#ZFG#T@HIQ#;?'-5%))+-"$.<# -'#T@HIK#;+")2+2&2+-"$.<#5-'*$2#$)#$??'-?'+$2%9#&)+"/# 23%#B%')+-"#$:-?2%:#$)#$#"$2+-"$.#)2$":$':#&":%'#23%# N%$.23# K")&'$"8%# Q-'2$,+.+2(# $":#!88-&"2$,+.+2(#!82# ;NKQ!!<6#!::+2+-"$.# +"5-'*$2+-"# -"# 23%)%# 5-'*$2)#8$"#,%#5-&":#$2# ElectronicBillingEDITrans/08_HealthCareClaims. $)? on the CMS website. L/""/)0+%)*+F'*/)0+<.K(/$.4.)#&+MN.)+,(34/##/)0+F"%/4&+#'+D/&-%"+9)#.$4.*/%$/.&O2L+ :.*/-%$.+2*4/)/&#$%#/7.+F')#$%-#'$&+PD9&O2L+:2F&Q When submitting claims to FIs/AB MACs with HCPCS code G0389, Medicare providers must report the $??'-?'+$2%#'%B%"&%#8-:%9#$":#23%#8-''%)?-":+"/#:+$/"-)+)#8-:%#+"#23%#NKQ!!#T@H#K")2+2&2+-"$.#%.%82'-"+8# 8.$+*#5-'*$26# >6=?R+ In those cases where an institution qualifies for an exception to the ASCA requirement, Form CMS-1450 may be used to submit these claims on paper. As of May 23, 2007, all providers must use Form CMS-1450 (UB-04) when submitting paper claims. Additional information on Form CMS-1450 can be found at the CMS website. =5H.&+'1+L/""&+1'$+D9&O2L+:2F& The FI/AB MAC will reimburse for the AAA ultrasound screening service when submitted on the following Types of Bills (TOBs) and associated revenue codes listed in Table 2: =%3".+B+I+D%-/"/#5+=5H.&S+=5H.&+'1+L/""&S+%)*+<.7.)(.+F'*.&+1'$+222+!"#$%&'()*+,-$..)/)0+,.$7/-. D%-/"/#5+=5H. =5H.+'1+L/"" <.7.)(.+F'*. N-)?+2$.#K"?$2+%"2#Q$'2#R# including Critical Access Hospital (CAH) FGZ 040X N-)?+2$.#[&2?$2+%"2 F@Z 040X &5!-,1)&0($1+-##0'0%$2)-$,8()*'0,5$,)-!'+$,0#&-31*1$$!"

4 D%-/"/#5+=5H. =5H.+'1+L/"" <.7.)(.+F'*. SNF Outpatient GGZ 040X Rural Health Clinic (RHC) 040X Federally Qualified Health Center (FQHC) CAH** 7$'(.$":#N-)?+2$.#&":%'# \&'+):+82+-"#-5#23%#N%$.23# Services Cost Review Commission (HSCRC) Indian Health Service (IHS) Provider IHS Inpatient Part B including CAH HFZ H@Z TMZ FGZ#]#F@Z FGZ AMGZ# See Additional Billing Instructions for RHCs and FQHCs AMGZ# See Additional Billing Instructions for RHCs and FQHCs 040X 040X 024X IHS CAH TMZ AMFZ T>6=?R+ The Skilled Nursing Facility (SNF) consolidated billing provision allows separate Medicare Part B payment for ultrasound screening services for beneficiaries that are in skilled Part A SNF stays; however, the SNF must submit these services on a 22X bill type. Ultrasound screening services provided by other provider types must be reimbursed by the SNF. TT>6=?R+7%23-:#K#I#!..#2%83"+8$.#8-*?-"%"2)#$'%#?$+:#&)+"/#)2$":$':#+")2+2&2+-"$.#,+..+"/#?'$82+8%)6 + +Method II - Receives payment for which Method I receives payment, plus payment for professional services in one of the following revenue codes: 096X, 097X, and 098X. P=N/&+H.$#%/)&+#'+ HN5&/-/%)&OH$%-#/#/').$&+8N'+N%7.+$.%&&/0).*+#N./$+3/""/)0+$/0N#&+#'+#N.+:.#N'*+99+F2JAQ Additional Billing Instructions for Rural Health Clinics (RHCs) and Federally Qualified J.%"#N+F.)#.$&+PDUJF&Q RHCs and FQHCs should follow these additional billing instructions to ensure that proper payment is made for services and to allow the Common Working File (CWF) to perform age and frequency editing. =.-N)/-%"+F'4H').)# for Provider-Based RHCs and FQHCs: The base provider can bill the technical component of the service to the FI/AB MAC under the base provider s ID number, following instructions for submitting claims to the FI/AB MAC from 23%#,$)%#?'-B+:%'6 =.-N)/-%"+F'4H').)# for Independent RHCs and FQHCs: The practitioner can bill the technical component of the service to the carrier/ab MAC under 23%#?'$82+2+-"%'D)#K^#"&*,%'9# "/#+")2'&82+-")#5-'#)&,*+22+"/#?'$82+2+-"%'#8.$+*)#2-#23%# carrier/ab MAC. 69$ &5!-,1)&0($1+-##0'0%$2)-$,8()*'0,5$,)-!'+$,0#&-31*1

5 # ;$'1.&&/')%"+F'4H').)# for Provider-Based RHCs and FQHCs, Independent RHCs, and Freestanding FQHCs: When a physician or qualified non-physician practitioner furnishes an ultrasound screening for AAA within an RHC/FQHC, the screening is considered an RHC/FQHC service. The provider of an ultrasound screening for AAA service must bill the FI/AB MAC under bill 2(?%#HFZ#-'#H@Z#'%)?%82+B%.(6# If the ultrasound screening is provided in an RHC or FQHC, the professional portion of the service is billed to the FI or AB MAC using the appropriate site of service revenue code in the 052X revenue code series and must include HCPCS code G0389 for the appropriate application of deductible. FQHC services are always exempt from the Part B deductible; however, RHCs are %>%*?2#5'-*#23%#:%:&82+,.%#5-'#23+)#)%'B+8%6 <./43($&.4.)#+9)1'$4%#/') V.).$%"+9)1'$4%#/') =3%'%#+)#"-#7%:+8$'%#Q$'2#R#:%:&82+,.%6#N-4%B%'9#23%#8-+")&'$"8%#-'#8-?$(*%"2#+)#$??.+8$,.%6# <./43($&.4.)#+'1+F"%/4&+35+F%$$/.$&O2L+:.*/-%$.+2*4/)/&#$%#/7.+F')#$%-#'$&+P2L+:2F&Q 7%:+8$'%#'%+*,&')%)#23%#&.2'$)-&":#)8'%%"+"/#?'-8%:&'%#5-'#!!!# under the Medicare Physician Fee Schedule (MPFS), when the provider bills the carrier/ab MAC. <./43($&.4.)#+'1+F"%/4&+35+D/&-%"+9)#.$4.*/%$/.&O2L+ :.*/-%$.+2*4/)/&#$%#/7.+F')#$%-#'$&+PD9&O2L+:2F&Q!::+2+-"$.# +"5-'*$2+-"# $,-&2# MPFS can be found at cms.hhs.gov/physicianfeesched on the CMS website. Reimbursement for the ultrasound screening for AAAs depends on the type of facility providing the service. Table 3 lists the type of payment that facilities receive for the AAA ultrasound screening service: =%3".+E+I+D%-/"/#5+;%54.)#+:.#N'*'"'05+1'$+!"#$%&'()*+,-$..)/)0+1'$ #N.+D%-/"/#5+/&+%W Hospital Subject to the Outpatient Prospective Payment System (OPPS) Critical Access Hospital (CAH), Method I or Method II Technical Component only Critical Access Hospital (CAH), Method# II Professional Component only Indian Health Service (IHS) Provider Outpatient IHS Provider Hospital Inpatient Part B IHS CAH =N.)+;%54.)#+9&+L%&.*+6)AAA OPPS FAF_#-5#'%$)-"$,.%#8-)2 FFM_#-5#"-"I5$8+.+2(#'$2%#-5#7%:+8$'%#Q3()+8+$"# Fee Schedule (MPFS) [7RI$??'-B%:#[&2?$2+%"2#Q%'#`+)+2#!..IK"8.&)+B%# Rate (AIR) All-Inclusive Inpatient Ancillary Per Diem Rate 101% of the All-Inclusive Facility Specific Per Visit Rate &5!-,1)&0($1+-##0'0%$2)-$,8()*'0,5$,)-!'+$,0#&-31*1$$!#

6 91+#N.+D%-/"/#5+/&+%W IHS CAH Hospital Inpatient Part B Indian Health Service (IHS) Provider Outpatient Rural Health Clinic (RHC)* Skilled Nursing Facility (SNF)** Federally Qualified Health Center (FQHC)* 7$'(.$":#N-)?+2$.#&":%'#\&'+):+82+-"#-5#23%# Health Services Cost Review# Commission (HSCRC) =N.)+;%54.)#+9&+L%&.*+6)AAA 101% of the All-Inclusive Facility Specific Per Diem Rate OMB-approved Outpatient Per Visit AIR All-Inclusive Encounter Rate Non-Facility Rate on the MPFS All-Inclusive Encounter Rate 94% of provider submitted charges or according 2-#23%#2%'*)#-5#23%#7$'(.$":#W$+B%' T>6=?R+ +++If the ultrasound screening is provided in an RHC or FQHC, the professional portion of the service is billed to the FI/AB MAC using TOBs 71X and 73X, respectively, and the appropriate site of )%'B+8%#'%B%"&%#8-:%#+"#23%#AMGZ#'%B%"&%#8-:%#)%'+%)6#K5#23%#&.2'$)-&":#)8'%%"+"/#+)#?'-B+:%:#+"# an independent RHC or freestanding FQHC, the practitioner can bill the technical component of the service to the carrier/ab MAC under the practitioner s ID following instructions for submitting practitioner claims to the carrier/ab MAC. If the ultrasound screening is provided in a# provider-based RHC/FQHC, the base provider can bill the technical component of the service to the FI/AB MAC under the base provider s ID, following instructions for submitting claims to the FI/AB MAC from the base provider. TT>6=?R+The SNF consolidated billing provision allows separate Part B payment for ultrasound screening services for beneficiaries that are in skilled Part A SNF stays; however, the SNF must submit 23%)%#)%'B+8%)#-"#$#GGZ#,+..#2(?%6#C.2'$)-&":#)8'%%"+"/#)%'B+8%)#?'-B+:%:#,(#-23%'#?'-B+:%'#2(?%)# must be reimbursed by the SNF. <.%&')&+1'$+F"%/4+G.)/%" =3%# "/#$'%#%>$*?.%)#-5#)+2&$2+-")#43%"#7%:+8$'%# may deny coverage of AAA ultrasound screening: =3%#,%"%5+8+$'(#:+:#"-2#'%8%+B%#$#'%5%''$.#5-'#23%# AAA ultrasound screening as a result of the IPPE. The beneficiary previously has received a covered!!!#&.2'$)-&":#)8'%%"+"/6 :.*/-%$.+F')#$%-#'$+ F')#%-#+9)1'$4%#/') To obtain car r ier/a B M AC and FI /A B MAC contact information, visit 8*)633)6/-BV7aYQ'-:&82)V^-4".-$:)V CallCenterTollNumDirectory.zip#-"#23% CMS website. 6:$ &5!-,1)&0($1+-##0'0%$2)-$,8()*'0,5$,)-!'+$,0#&-31*1

7 7%:+8$'%#?'-B+:%')#*$(#5+":#)?%8+5+8#?$(*%"2#:%8+)+-"# information on the remittance advice (RA). The RA will include Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) that provide $::+2+-"$.#+"5-'*$2+-"#-"#?$(*%"2#$:\&)2*%"2)6#=3%#*-)2# 8&''%"2#.+)2+"/#-5#23%)%#8-:%)#8$"#,%#5-&":#$2# wpc-edi.com/codes# -"# 23%# 4%,6# Q'-B+:%')# 8$"# -,2$+"# $::+2+-"$.#+"5-'*$2+-"#$,-&2#8.$+*)#5'-*#23%#8$''+%'V!R# MAC or FI/AB MAC. <.4/##%)-.+2*7/-.+9)1'$4%#/') =-#-,2$+"#*-'%#+"5-'*$2+-"#$,-&2#23%#'%*+22$"8%# advice (RA), visit MLNProducts/downloads/RA_Guide_Full_03- GGIAL6?:5 on the CMS website. Written Advance Beneficiary Notice Of Noncoverage (ABN) Requirements Please refer to the Advance Beneficiary Notice of Noncoverage (ABN) Reference Section G of this publication. &5!-,1)&0($1+-##0'0%$2)-$,8()*'0,5$,)-!'+$,0#&-31*1$$!$

8 Beneficiary Notices Initiative Website+ 23*'4/)%"+2'$#/-+2).($5&4& <.&'($-.+:%#.$/%"& F%$$/.$O2L+:2F+%)*+D9O2L+:2F+F')#%-#+9)1'$4%#/') :.*/-%$.+D..XD'$X,.$7/-.+;$'7/*.$&+M.3&/#.+ This site contains detailed provider-specific information, including information about the Clinical Laboratory Fee Schedule.# :.*/-%$.+].%$)/)0+>.#8'$C+P:]>Q+ The Medicare Learning Network (MLN) is the brand name for official CMS educational products and +"5-'*$2+-"#5-'#7%:+8$'%#5%%I5-'I)%'B+8%#?'-B+:%')6#P-'#$::+2+-"$.#+"5-'*$2+-"#B+)+2#23%#7%:+8$'%#a%$'"+"/# Y%24-'OD)#4%,#?$/%#$2# on the CMS website. :.*/-%$.+;N5&/-/%)+D..+,-N.*(".+9)1'$4%#/')+ :.*/-%$.+;$.7.)#/7.+,.$7/-.&+V.).$%"+9)1'$4%#/')+ :]>+;$.7.)#/7.+,.$7/-.&+?*(-%#/')%"+<.&'($-.+M.3&/#.+ >%#/')%"+F'$$.-#+F'*/)0+9)/#/%#/7.+?*/#&+M.3&/#.+ National Provider Identifier Information+ ;N5&/-/%)+9)1'$4%#/')+<.&'($-.+1'$+:.*/-%$.+M.3&/#.+ This site contains physician-specific information, including updates to policies, regulations, coding and 8-B%'$/%#+"5-'*$2+-"9#?'-/'$*#+"2%/'+2(#+"5-'*$2+-"9#$":#-23%'#B$.&$,.%#'%)-&'8%)6# + L.).1/-/%$5X$."%#.*+$.&'($-.&+-%)+3.+1'()*+/)+<.1.$.)-.+D+'1+#N/&+V(/*.A 7;$ &5!-,1)&0($1+-##0'0%$2)-$,8()*'0,5$,)-!'+$,0#&-31*1

9 <.4/##%)-.+2*7/-.+9)1'$4%#/') This website provides the USPSTF written recommendations.# M%&N/)0#')+;(3"/&N/)0+F'4H%)5+PM;FQ+F'*.+]/&#&+ WPC assists in the maintenance and distribution of HIPAA-related code lists that are external to the X12 5$*+.(#-5#)2$":$':)6# + L.).1/-/%$5X$."%#.*+$.&'($-.&+-%)+3.+1'()*+/)+<.1.$.)-.+D+'1+#N/&+V(/*.A &5!-,1)&0($1+-##0'0%$2)-$,8()*'0,5$,)-!'+$,0#&-31*1$$ %&