Sage Screening Program. Provider Manual

Transcription

1 Sage Screening Program Provider Manual Sage Screening Program Minnesota Department of Health 85 E. 7th Place, Suite 400 P.O. Box St. Paul, Minnesota (651) (phone) (651) (fax) (651) (TTY) ADA notice: if you require this document in another format, such as large print, Braille or cassette tape, call (651) Revised 2/15 1

2 Table of Contents: 1 Overview pg 2 2 Eligibility pg Covered services pg Coverage of screening services pg Coverage of treatment services pg Periodicity of covered services pg Services not covered pg 5 4 Coverage of treatment pg 6 5 Enrolling women in Sage - pg Information to be completed by the patient pg The Sage Screening Program office visit pg Re-enrolling women in the Program pg 8 6 Referring for mammograms and breast ultrasounds pg Screening mammograms pg Follow-up mammograms pg Breast ultrasounds pg 9 7. Cervical testing pg Pap Smears pg HPV High Risk DNA Panel pg Colposcopy pg Coordinating with other providers pg Referral outside the site facility pg Outpatient breast diagnostic procedure pg Tracking and follow-up pg Normal test results pg Abnormal test results pg Assisting women - pg Follow-up forms pg Rescreening pg Imaging services pg Screening mammograms pg Additional mammographic Views pg Follow-up mammograms pg Breast ultrasounds pg Breast US immediate work-up pg Short term follow-up us pg Completing the form for an US- pg Other imaging services (breast MRI, X- ray, etc.) pg Lab services pg Pap tests pg Completing the Pap form pg HPV High Risk DNA Panel pg Pathology pg Billing and reimbursement pg Basic requirements pg CPT Codes pg Rates pg Submitting claims pg Patients with insurance pg Payment pg Credits pg Remittance pg Billing technical assistance pg Patient recruitment pg Inreach pg Outreach pg Resources and tools pg Collaborations pg Special population grants pg State-wide efforts pg Professional education pg Provider agreement pg Quality assurance pg Confidentiality pg Data privacy pg Sage smoking policy pg 28 Appendix (not available on-line) A- Sage Forms and instructions A1- Sage Enrollment form A2- Sage Imaging Summary A3- Sage Pap Summary B- Provider Agreement 1

3 1. Overview The Sage Screening Program is a partnership between public health and the private healthcare system. The goal of the Sage Screening Program is to remove the barrier of cost so low to moderate income Minnesota women (age 40 and over), who are uninsured or underinsured, can receive quality breast and cervical cancer screening, free of charge. The program is funded through a cooperative agreement with the Centers for Disease Control and Prevention under the Breast and Cervical Cancer Mortality Prevention Act of 1990, as well as funds from the state of Minnesota and some private organizations. 2. Eligibility Women must meet all four eligibility criteria listed below: 1. They must be age 40 or older Exception: The Sage Screening Program services are intended for women age 40 and older. To be eligible for breast cancer screening services, a woman under 40 years of age must either demonstrate breast symptoms where it is important to rule out breast cancer as a cause (i.e. lump, bloody nipple discharge, skin dimpling, inflammation), or report a family history of breast cancer where a 1 st degree relative has had the disease (parent, sibling, or child). Women under age 40 are NOT eligible to have Pap smears or colposcopies paid for by the Sage Screening Program under any circumstances 2. They must have no insurance, or be underinsured. Underinsured refers to women who have insurance that does not fully cover the cost of screening services, have unmet deductibles or a significant co-pay (co-pays should not be collected from Sageenrolled women), or other out-of-pocket expenses. This may include patients on Medicare (especially if they do not have a Medicare supplemental policy). Note: Health Savings Accounts (HSA) administered by a Health Plan for patient s with high deductibles are not part of it s insurance coverage and Sage should pay in advance of those funds. Medical Assistance and Minnesota Care will fully pay for the services Sage would cover. Women covered by these programs don t need Sage, and should not be enrolled. 3. They must be a Minnesota resident. Women, who live in Minnesota, either year-round or seasonally, are eligible for the Sage Screening Program services if they meet the program s income and insurance guidelines. Non-Minnesota women should be referred to the Breast and Cervical Cancer Early Detection Program in their state of residence to determine eligibility for services in their own state s program. Phone numbers for other state programs can be obtained by calling

4 Non-Minnesota residents from adjacent states are eligible for the Sage Screening Program if they are between the ages of 50 and 64 and meet Sage s income and insurance guidelines. These women are NOT eligible for treatment coverage under the Minnesota Treatment Act (Section 4), and as a result of participating in Sage, may become ineligible for coverage under their state s Treatment Act. 4. Have income within the guidelines listed on the following table: Household Number 2015 Income Guidelines Monthly Income Yearly Income 1 2,452 29, ,319 39, ,185 50,225 5, , , ,785 81,425 Add for each additional ,404 Determining Household Income Use gross income, unless self-employed or farmers who should use their gross income minus business expenses. Since monthly incomes may vary, use a current or recent month s estimate of monthly income. No documentation is required. Determining Household Size All persons living in the same house and being supported by the reported income, should be included in the determination of household size. 71,025 Guidelines change yearly. Sage provides updates on its website early each year. 3. Covered services The following services are free of charge to eligible women at participating facilities: 3.1 Screening Services Office visit for breast and/or pelvic exam. Pap smear Women can receive Pap testing every 3 years Women who have had a total hysterectomy (i.e., those without a cervix), should not have a Pap test done under the Sage Program; unless 1. the hysterectomy was performed because of cervical neoplasia (CIN) or invasive cervical cancer, or 2. if it was not possible to document the absence of neoplasia or reason for the hysterectomy. Note: The medical recommendations regarding screening for women who have had a hysterectomy for CIN or cervical cancer. o Women who have had a hysterectomy for CIN disease should undergo cervical cancer screening for 20 years even if it goes past the age of 65. o Women who have had cervical cancer should continue screening indefinitely as long as they are in reasonable health. 3

5 For women who have had a total hysterectomy for non-cancer reasons, Sage supports the recommendation of a yearly pelvic along with a breast exam. Sage cannot pay for an office visit in which only a pelvic exam is done. Screening mammograms must be accompanied by a current clinical breast exam done at a Sage Screening Program participating clinic. For dates of service prior to June 30, 2009, Sage will reimburse digital mammograms at conventional CMS rates. On or after June 30, 2009, Sage will reimburse digital mammograms at the full CMS digital rate. Computer Assisted Detection (CAD) with mammography. 3.2 Diagnostic Services Diagnostic services will only be provided to Sage Screening Program participants whose initial test results indicate a need for additional evaluation to rule out cancer. Follow-up office visits o Repeat clinical breast and pelvic exams as often as clinician recommends (Sage cannot cover an office visit for a pelvic exam only) o Office visits to discuss abn. results, including surgical consultations. Diagnostic mammogram (including CAD). Breast ultrasound Fine needle aspiration (including pathology). Outpatient Breast Biopsy o Special arrangements are necessary for coverage of breast biopsies (and certain other breast diagnostic procedures) through the Sage Screening Program, whether the procedure is performed at your clinic or referred out. (refer to Sect. 10 on how to arrange biopsy coverage). Human Papilloma Virus (HPV) High Risk DNA Panel coverage: o Sage will cover a High Risk HPV DNA Panel when done to triage an ASC-US or LSIL* Pap result when the Pap was covered by Sage. This can be done either reflexively from the original Pap specimen if it was a liquid-based Pap, or by a return office visit (also covered) where the HPV sample is collected (kit to collect sample is not covered). o Sage will cover a High Risk HPV DNA Panel when done for a 12 month follow-up after a colposcopy that was indicated by an ASC-H Pap or LSIL Pap (the colposcopy result cannot have been CIN 2 or 3). o Sage will cover a High Risk HPV DNA Panel when done for a 12 month follow-up after a colposcopy that was indicated by an ASC-US Pap (the colposcopy result cannot have been CIN AND there must have been a + HPV at the time of the colposcopy). o Sage will cover a High Risk HPV DNA Panel when done at the time of colposcopy for workup of a AGC-NOS Pap result (endocervical cells). There is nothing to mark on the Sage Enrollment form for this situation, but a note should be placed in the Comments area of the form to the effect that an HPV test on a AGC-NOS Pap was collected with this colposcopy. Also a Sage HPV High Risk DNA Panel form should be sent to Sage with the same encounter Number as the Enrollment form. 4

6 * in a postmenopausal woman Colposcopy of the cervix (including biopsy and ECC/ECS) o For patients for whom there is documentation of an immediatley prior abnormal Pap smear. Endometrial Biopsy o For patients whose screening Pap smear was done under Sage. o Pap result must be: any Atypical Glandular Cell finding (Examples: Atypical Endocervical cells, Atypical Endometrial Cells, Atypical Glandular Cells, Endometrial Cells [in a woman > 40 years of age], and Adenocarcinoma). Excision of breast lesions o After a diagnosis of Fibroadenoma (FA) is established with tissue sampling (biopsy), an excision of the FA may be covered in the following instances only: 1. Hyperplasia or atypical cells on pathology 2. Large size: 5 cm or greater (can obscure a malignancy) 3. Change in size or appearance as demonstrated on 6 month follow-up 4. Not FA, but a Phyllodes tumor o Note: Sage cannot cover excision for patient comfort or aesthetic reasons 3.3 Service Periodicity: Pap smear - Sage covers Pap smears (either conventional or Liquid-based) every 3 years. Follow-up to abnormal Pap smear - Following an abnormal Pap result Sage will cover all testing or retesting according to the timeframes established in the ASCCP Consensus Guidelines for the Management of Women with Cervical Cytological Abnormalities Pelvic exam - The Sage Program will pay for an office visit for an annual pelvic exam if during the office visit: 1) a Pap smear is collected according to Sage Pap periodicity policy, 2) a clinical breast exam (CBE) is preformed or 3) both a Pap and CBE are performed. 3.4 Services not covered by the Sage Screening Program Only the services listed above are covered. Some services that are commonly billed to the Sage Screening Program, but are not covered, include: Evaluation of vaginal or vulvar lesions. Removal of cervical polyps. Blood work. Urinalysis. Pelvic ultrasounds. Endometrial biopsy done for vaginal bleeding work-up. Any type of treatment for cancer or precancerous lesions (refer to MABC). 5

7 Before providing services which are not covered by the Sage Screening Program, please inform the patient that she will be responsible for payment for these services. Sage provides a document which may be used to inform patients of services that are not covered. This can be ordered from the Sage Screening Program using Clinical Forms and Supplies Order Form or on the Sage website. For other resources available for services not covered by the Sage Screening Program, call your Regional Coordinator. Note: Medicare patients enrolled in Sage should sign the Medicare Advanced Beneficiary Notice (ABN) to enable labs and hospitals to submit claims to the Sage Program. 4. Coverage of treatment services Patients, who have been screened through the Sage Screening Program and found to need treatment for breast cancer, cervical cancer, or a pre-cancerous cervical condition, may be eligible for a program that will cover the costs of such treatment. The Minnesota Department of Human Services has established a category of Medical Assistance (MA) called MA-BC which has eligibility guidelines that are less restrictive than current MA programs. The eligibility criteria are: 1) was screened through the Sage Screening Program; 2) has no insurance to cover treatment costs (including Medicare) and 3) has an immigration status that qualifies for either federal or state MA. Please see for complete details on MA-BC eligibility. Patient application forms for MA-BC are available at the local county social services office. MA-BC also offers a Presumptive Eligibility component which allows a woman who has been screened through the Sage Screening Program and found to need treatment a 30-day period of automatic coverage, regardless of her ultimate eligibility for MA-BC. In other words, even if a woman is determined by the County to be ineligible for MA-BC (after filing an application) any treatment costs incurred during the Presumptive Eligibility period will still be covered. To learn more about this contact your Sage Regional Coordinator. 5. Enrolling women in Sage Enrolling women in the Sage Screening Program is done by having the patient complete the blue Sage Enrollment form [Appendix A1]. This form is used whether the patient is new to Sage or has been covered by the program before. Instructions for this form can be found in Appendix B1. Eligible women enroll by completing pages 1 3 of the (blue) Enrollment Form (available in both English and Spanish). The clinic assigns an encounter number which should be placed on the Enrollment form, Pap Summary, Imaging Summary and any other related Sage forms (i.e. HPV high Risk DNA 6

8 Panel form) and must appear on all related bills submitted to Sage. Encounter numbers are unique to each screening site and each visit needs a new encounter number. 5.1 Information to be completed by patient Pages 1 3 of the (blue) Enrollment form should be completed by the patient before her Sage exam. Please note that patients cannot be enrolled in Sage without a completed Permission for Release of Information with a current date. This permission provides information to the patient on how the clinic and Sage will use the information collected on the form, and it allows providers to release the required medical information to the Sage Screening Program. The Sage Screening Program complies with all state and federal data privacy laws. Sage is not a HIPAA-covered entity. 5.2 The Sage Screening Program office visit Once enrolled, the patient must have a clinical breast examination (and Pap smear, if indicated) by a clinician at a Sage Screening Program screening site before receiving a mammogram. The exam may be done by a physician, nurse practitioner, physician assistant, or nurse midwife. If breast screening isn t necessary, a cervical screening only visit is acceptable. Upon completion of the Sage Screening Program patient visit, the clinician must complete the Visit Summary portion of the blue Enrollment Form. Please review the form for completeness, enter the patient into the tracking system (please refer to Section 11 of this manual for more information about tracking system requirements), make a copy for your records, and mail the original copy to the Sage Screening Program as soon as possible. To ensure that women are tracked adequately and that bills are paid quickly, it is crucial that the Sage Screening Program receive enrollment or return visit forms within 1-2 weeks of the exam. The Sage Screening Program will not accept forms later than 6 months from the date of the office visit. 7

9 If a mammogram was ordered, it is necessary to inform the mammography facility of the patient s encounter number. This can be done either by sending the mammography facility a Sage Imaging Summary form (green) with the patients name and encounter number, or by giving them the patient s Encounter Number so they can initiate the Sage Imaging Summary form. If a Pap test was done, send the specimen to the lab with the patient s encounter number. Use the pink Pap Summary form unless alternate arrangements have been made. If a breast ultrasound was ordered, it is necessary to inform the ultrasound provider of the patient s encounter number. This can be done either by sending the ultrasound provider a Sage Imaging Summary form with the patient s name and encounter number or by giving them the patient s Encounter Number so they can initiate the Sage Imaging Summary form. 5.3 Re-enrolling women in the Sage Screening Program The Sage Enrollment form (blue) is used for all patients enrolling in Sage. If they are returning Sage patients, simply make sure to check the appropriate box on the top of the back page of the form. NOTE: Short-term follow-up services- the form is necessary to report services that occur within 6 months of the patient s initial screening, even if the patient is not seen again in the clinic. In this case, the visit date should reflect the date the follow-up service is performed, and the box checked for either breast ultrasound ordered or done this visit and/or mammogram ordered or done this visit. 6. Referring for mammograms and breast ultrasounds This section provides direction to Sage Screening sites making referrals for imaging services through the Sage Screening Program. For information for those working in mammography/ultrasound facilities and/or radiology groups, see Imaging Services in Section 12. The Sage Imaging Summary is used for all imaging. 6.1 Screening Mammograms After the screening site has enrolled the patient in Sage and completed a clinical breast exam, the screening site can schedule the mammogram and send the Sage encounter number to the imaging facility. The encounter number can be relayed to the mammography facility either by sending the (green) Sage Imaging Summary form [Appendix A2] or by providing the mammography facility the patient s encounter number when the appointment is scheduled. The ordering physician will receive their usual mammography report and Sage will also receive the patient s results. If additional imaging is desired by the radiologist, the imaging facility will fill 8

10 out an additional Sage Imaging Summary for each type of imaging service provided. Instructions for the Sage Imaging Summary form can be found in Appendix B Follow-up mammograms The Sage Screening Program will reimburse for short term follow-up mammograms that are recommended by the clinician or radiologist. If the follow-up mammogram is within 12 months of the original screening tests, another clinical breast exam in not necessary. For follow-up mammograms, a Sage Enrollment form with a new encounter number should be completed, either by the screening site or by the Imaging Service Provider (even if the patient is not seen again at the clinic). The patient s signature is not required if within 9 months of the last signature (write signature within 9 months on signature line). The mammogram date should be recorded as the visit date and the mammogram ordered or done box should be checked. A new (green) Sage Imaging Summary form needs to be completed and sent to Sage. 6.3 Breast ultrasounds Sage Screening Program will reimburse for breast ultrasounds when recommended by a clinician or radiologist for follow-up of an abnormal clinical breast exam or an abnormal mammogram. When referring a patient for an ultrasound to an imaging facility, make sure the facility has the patient s encounter number. In cases in which a repeat ultrasound (i.e. three to six months later) is recommended to follow-up on a probably benign finding, a Sage Enrollment form (even if the patient is not seen again at the clinic) with a new encounter number should be completed, either by the screening site or by the Imaging Service Provider. The patient s signature is not required if within 9 months of the last signature (write signature within 9 months on signature line). The breast ultrasound date should be recorded as the visit date and the breast ultrasound ordered or done box should be checked. A new (green) Sage Imaging Summary needs to be completed and sent to Sage. 7. Cervical screening This section provides information to Sage Screening Program screening sites for handling lab services ordered through Sage. Guidance for cytology laboratories and pathologists can be found under Lab Services in Section Pap Testing The Sage Screening site enrolls the patient in Sage and assigns an encounter number. The site then does an exam and sends the Pap slide or specimen to the lab, with the encounter number noted, on a (pink) Pap Summary form (unless other reporting arrangements have been made). The ordering physician will receive their usual Pap result and Sage will also receive the patient s result. The clinic is responsible for notifying the patient of the results. 9

11 7.2 HPV High Risk DNA Panel The Sage Screening Program reimburses for HPV DNA testing only under certain circumstances (below) and NOT as an adjunct to screening. The HPV test is done to determine the need for colposcopy. Sage will reimburse: 1. Only for the High Risk DNA Panel. 2. Only an FDA approved test can be reimbursed. 3. Only one test / person / date can be reimbursed. Sage will cover a High Risk HPV DNA Panel when done to triage an ASC-US or LSIL* Pap result when the Pap was covered by Sage. This can be done either reflexively from the original Pap specimen if it was a liquid-based Pap, or by a return office visit (also covered) where the HPV sample is collected (kit to collect sample is not covered). Sage will cover a High Risk HPV DNA Panel when done for a 12 month follow-up after a colposcopy that was indicated by an ASC-H or LSIL Pap (the colposcopy result cannot have been CIN 2 or 3). Sage will cover a High Risk HPV DNA Panel when done for a 12 month follow-up after a colposcopy that was indicated by an ASC-US Pap (the colposcopy result cannot have been CIN AND there must have been a + HPV at the time of the colposcopy). Sage will cover a High Risk HPV DNA Panel when done at the time of colposcopy for workup of a AGC-NOS Pap result (endocervical cells). There is nothing to mark on the Sage Enrollment form for this situation, but a note should be placed in the Comments area of the form to the effect that an HPV test on a AGC-NOS Pap was collected with this colposcopy. Also a Sage HPV High Risk DNA Panel form should be sent to Sage with the same encounter Number as the Enrollment form. * for a postmenopausal woman Methods for HPV Testing Liquid based Pap test: reflexive HPV High Risk DNA testing can be done on the original sample, and reported on the Pap Summary, and no second visit or new encounter number is needed. Conventional Pap smear: The woman will need to return to the clinic for HPV High Risk DNA Panel collection. Complete a (blue) Sage Enrollment form with a new encounter number. In the Cervical Information section of the Visit Summary, check: HPV Test done at this visit for prior Sage Pap with ASC-US result. Complete a Sage HPV High Risk DNA Panel form using the new encounter number assigned to this visit. Send the specimen and Sage paperwork to the lab that does your clinic s HPV testing. 10

12 7.3 Colposcopy Sage will reimburse for colposcopy (with cervical biopsy and /or histological endocervical sampling (ECC or ECB), or both). Patients must have a documented recent abnormal Pap smear indicating the need for colposcopy or a prior abnormality requiring surveillance. 8. Coordinating with other providers Because of the interdependence of all service providers working with the Sage Screening Program, a good line of communication should be established with each facility (e.g. the clinic, mammography facility, Pap lab) the screening site will be working with to coordinate care for Sage patients. This may be as simple as identifying a contact person name and phone number at each facility and holding an annual or semi-annual meeting. Each service provider has to complete their steps in the Sage Program process in order for the next step to work. The coordination established will help solve system or individual problems before they get out of hand. Sage Program staff is always available for assistance in establishing these links and resolving any problems that may occur. 9. Referral outside the Sage Screening site facility Some Sage Screening Program providers may not offer one or more of the follow-up services that the Sage program will pay for (i.e. colposcopy). When this occurs, the patient should be referred to another Sage participating facility that offers the necessary service. That facility would then enroll her under their encounter number for that service. In the instance when the only available referral facility for the service is not a Sage Screening Program provider, the referring Sage facility must make billing arrangements with the referral provider to assure that Sage Program funds will pay for the service and the woman will not be billed. 10. Outpatient breast diagnostic procedures Sage Screening Program will cover all costs normally associated with an approved outpatient breast diagnostic procedure, including surgical consultation, biopsy (whether open surgical, needle localization, or stereotactic), anesthesiology, pathology, lab work, and pre-op exam or consult. However, special arrangements must be made to bill these procedures, and prior authorization is required. The Sage Screening Program provider arranging the procedure must obtain an authorization number (M number) by contacting Sage at (651) Sage authorizes the procedure and assigns a unique (M) number to the procedure, completes the patient 11

13 information portion of the Outpatient Breast Diagnostic Procedure invoice, and mails four copies of this form for distribution. Once authorization is received, all parties involved in the procedure must be contacted and given the Sage-provided M# authorization. In no case should the patient be held responsible for any part of the bill. The Sage Program will reimburse at current Medicare rates. Upon receiving Outpatient Breast Diagnostic Procedure invoices, one copy should be distributed to each of the (billing) entities involved in providing the breast procedure, (i.e. anesthesiologist, radiologist, surgeon and hospital). Each of these entities should complete their copy of the form and submit it to Sage for reimbursement. The form should include the federal ID number of the organization to be paid and should have attached an itemized list of charges with CPT codes and any Explanation of Benefits (EOBs), if the patient has insurance. If an organization does not currently have a provider agreement with Sage, contact your Regional Coordinator to arrange it. 11. Tracking and follow-up A crucial component of the Sage Screening Program is to ensure that women with abnormal screening results, or women who have a diagnosis of cancer, receive timely and appropriate diagnostic, treatment, and rescreening services. Sage Screening sites are expected to maintain a system to enable them to track patient results, notify patients of their test results, follow-up with patients with abnormal results, and remind patients to return for rescreening Normal test results Screening sites should communicate normal test results to patients in writing or by telephone within ten days of receipt Abnormal test results Screening sites should attempt to notify a patient of an abnormal test results within 5 days of receipt. Several attempts to notify a patient should be made by phone. If you re unable to reach a patient by phone, a certified letter may be sent. All dates and attempts to reach a patient, as well as the follow-up recommendations, should be documented in the patient s medical record. The recommendations and a plan for follow-up should be clearly communicated to the patient Assisting women to obtain diagnostic/treatment services Securing diagnostic and/or treatment services for underinsured/uninsured women can be a challenge. It can involve the provision of follow-up care at the screening site, or a referral to an outside provider. If the service needed is a Sage covered service (see Section 3) a referral should be made to a Sage provider who can provide this service. For a current list of participating Sage Providers, see our website at: Sage Screening sites are expected to track patients with abnormal test results until they receive all their diagnostic/treatment services. Sage Screening sites should have a plan to assist women with abnormal test results receive the recommended care. Sites are expected to work with each woman to ensure that she understands the need for follow-up and knows where and how to access these services. Sites should be aware of the 12

14 resources available to women (including MinnesotaCare and MA/BC), and how to access these services. The Sage Screening Program Follow-up Coordinator and/or Case Manager may be able to assist you in identifying resources for patients. Before considering a patient as lost to follow-up, there should be a minimum of three separate attempts to contact the patient, the last attempt being through certified mail. Contact should be attempted at various times of day, and on various days of the week. Sage s Case Manager is also available to try to reach patients otherwise considered lost to follow-up. For Patients requiring treatment, remember that coverage might be available through MA-BC (see Section 4). Enrollment in Medical Assistance, MinnesotaCare, and setting up billing plans are other options for women when treatment is required. A limited number of additional resources have been identified by the Sage Screening Program, but these vary by locale. Contact your Sage Regional Coordinator for assistance Sage s role in patient tracking; Breast and cervical follow-up forms In order to assure that women with abnormal screening results receive timely and appropriate follow-up, the Sage Screening Program actively tracks the care received by women with abnormal screening results. The following findings are tracked: Breast exam suspicious for cancer; Mammogram result of Assessment Incomplete, Suspicious, or Highly Suggestive of Malignancy; Pap Smear results of ASC-H (Atypical Squamous Cells: cannot rule out High Grade), LSIL (Low Grade Squamous Intraepithelial Lesions), High Grade Squamous Intraepithelial Lesion (HSIL), Atypical Glandular (AGC), Adenocarcinoma, Squamous Cell Carcinoma, and positive High Risk HPV. Any colposcopy; and Any breast diagnostic procedure- ultrasound, fine needle aspiration or biopsy 13

15 The Sage Screening Program will generate and send to the screening site an Abnormal Follow-up Report for each woman with an abnormal test result approximately 45 days after the result or procedure date. This form should be completed by the health professional involved in the patient s care, and returned to Sage within two weeks. Instructions for completing the Abnormal Follow-up Report are found on the back of each report form. When completing the Follow-up form, be sure to document all diagnostic/treatment procedures and the date(s) of completion, as well as the status of the diagnostic work-up. If you are unable to provide the outcome information, please provide the name, address and phone number of the physician to whom this patient s care has been transferred to enable Sage to request follow-up information from that provider. Through the information provided on the Follow-up Reports, the Sage Screening Program monitors the follow-up care provided to women using guidelines developed by its Medical Advisory Committee. Providers may be contacted for additional information when questions arise, or if the care provided falls outside of the expected norm. The Sage Screening Program s expectation is that diagnostic care and treatment be provided as soon as possible. The Sage Screening Program s goals for both breast and cervical abnormalities are: Breast abnormalities: A diagnosis is reached within 60 days of an abnormal screening. Treatment is initiated within 30 days of diagnosis. Cervical abnormalities: A diagnosis is reached within 60 days of an abnormal screening. Treatment for high grade lesions and invasive cancer is initiated within 30 days of diagnosis Rescreening Sage Screening sites should remind women to return for rescreening as their recommended rescreening date approaches. To facilitate this, Sage will send screening sites monthly lists of Sage patients due for screening two months in advance of the recommended rescreening date reported to Sage. Screening sites may wish to coordinate reminders with the mammography providers, as many mammography providers routinely remind women directly. 12. Imaging services This section addresses the specific issues and paperwork related to mammography facilities, ultrasound providers, and radiology groups that provide Sage Screening Program services. Patients are enrolled in the Sage Program though a participating Sage Screening clinic: imaging service providers do not enroll patients in Sage. Prior to imaging, the patient should have a clinical breast exam through the Sage Program at one of these Sage Screening clinics (unless the imaging is short interval follow-up). Imaging service providers will know a patient has been enrolled in the Sage Screening Program when they receive a unique encounter number from the referring screening site at the time of referral. This encounter number is required to report test results and to bill the Sage Screening Program. Imaging service providers must report patient test results to the Sage Screening Program on the appropriate forms. 14

16 12.1 Imaging- Screening mammograms: The Sage Screening site notifies the mammography facility that a patient is part of Sage either by sending the facility a (green) Sage Mammogram Summary form [Appendix A2], with an encounter number or by providing the encounter number by phone when scheduling the patient s mammogram. Patients should have received a clinical breast exam at the Screening site prior to her mammogram and the mammogram should be completed within 4 months of this clinical breast exam. Instructions for completing the Sage Imaging Form can be found in Appendix B2. Screening mammograms may be of two different types and are categorized that way on the Sage Imaging form. One type is the normal annual screening mammogram that requires the normal mammographic projections. This is a category [1] on the form. The other type necessary for some women is also an annual screening mammogram, but requires extra mammographic projections. This is a category [2] on the form. Without the proper category Sage can t pay the extra amount that is deserved for a category [2] mammogram Imaging: Additional mammographic views When a patient s screening mammogram, either category [1] or [2], results are categorized as assessment incomplete additional mammographic views are often ordered. For these Second Mammograms (using diagnostic views), please fill out another green Sage Imaging form using the same encounter number as the initial screening mammogram. The category to select is [3]. Again, Sage cannot pay the increased compensation for the diagnostic views unless the proper category is selected Follow-up mammograms When a Sage screening mammogram result is an ACR category 3 (probably benign-short interval follow-up suggested) the Sage Screening Program will reimburse for short term follow-up mammograms that occur within 3 to 6 months of that original screening mammogram. If more than 12 months have elapsed since the screening, the clinical breast exam must be repeated (at a Sage Screening site). A (blue) Sage Enrollment form must be completed for each short-term follow-up imaging service/ mammogram provided, even if the patient was not seen again at the clinic. In addition, a new encounter number is needed and a new (green) Sage Imaging Summary form needs to be completed (see section 6.2) Imaging: Breast ultrasounds Sage will reimburse for breast ultrasounds when recommended by a clinician or radiologist for either immediate diagnostic work-up (for an abnormal CBE or for an abnormal or assessment incomplete screening mammogram), or short-term (3 6 month) follow-up of screening abnormality Breast ultrasound for immediate diagnostic work-up The facility performing the ultrasound will need to complete another green Sage Imaging Summary form for each patient receiving an ultrasound. The encounter number from the abnormal mammogram or CBE must be indicated on the form. 15

17 Only one ultrasound may be done per encounter number and should be billed under this encounter number Short term (3 6 Month) follow-up breast ultrasound When a short-term follow-up ultrasound is recommended to follow-up on an ultrasound finding that is probably benign, the clinic needs to submit a new Sage Enrollment form with a new encounter number. If no clinic visit occurs, the imaging provider will need to get a new encounter number from the screening clinic and indicate this encounter number on the Sage Imaging Summary form Completing the Sage Imaging Summary for a breast ultrasound. In section A of the green Sage Imaging Summary category [4] must be checked and other information for completing the Sage Imaging Form according to the instructions found in Appendix B Other imaging services (i.e. breast MRI, X-ray, etc.) When other types of imaging are ordered check with your regional coordinator to determine if Sage can cover it (clinical documentation may be required). 13. Lab services This section addresses the specific issues related to cytology laboratories and pathologists that provide Sage Screening Program services, outlines procedures for providing Sagecovered lab services, and gives instructions on completing the Pap Summary and the HPV High Risk DNA Panel forms. Specific CPT Codes that can be covered are listed on the Sage Screening Program Reimbursement Rates. (see NOTE: Lab service providers do not enroll patients in the Sage Screening Program. The patient must be enrolled through a Sage screening site prior to any service. Lab service providers will know a patient has been enrolled in the Sage Screening Program when they receive a unique Sage encounter number from the screening site with the specimen. This encounter number is also required on billing submission Pap Tests The Sage Screening site enrolls a patient in Sage and assigns an encounter number. The screening site does the exam, sends the Pap slide or specimen to the lab with the patient encounter number on a (pink) Pap Summary form (an alternative reporting format following the Bethesda terminology may be used with prior approval of Sage). The lab sends the usual Pap result to the clinic, and also sends the result to the Sage Program on the Pap Summary form (or actual report if pre-approved) Completing the Pap Summary form The Pap Summary Form [Appendix A3] should be completed by the cytotechnologist or pathologist and mailed to Sage. The instructions for filling out the Pap Summary are in Appendix B3. Please note that the Specimen Type: [1] Conventional, or [2] Liquidbased must be marked on the form or we cannot process the form or pay for the Pap test HPV High Risk DNA Panel 16

18 The Sage Screening Program reimburses for HPV DNA testing only under certain circumstances (below) and NOT as an adjunct to screening. The HPV test is done to determine the need for colposcopy. Sage will reimburse: 4. Only for the High Risk DNA Panel. 5. Only an FDA approved test can be reimbursed. 6. Only one test / person / date can be reimbursed. Sage will cover a High Risk HPV DNA Panel when done: 1. to triage an ASC-US Pap result when the Pap was covered by Sage. This can be done either reflexively from the original Pap specimen if it was a liquid-based Pap, or by a return office visit (also covered) where the HPV sample is collected (kit to collect sample is not covered). 2. for a 12 month follow-up after a colposcopy that was indicated by an ASC-H or LSIL Pap (the colposcopy result cannot have been CIN 2 or 3). 3. for a 12 month follow-up after a colposcopy that was indicated by an ASC-US Pap (the colposcopy result cannot have been CIN AND there must have been a positive HPV at the time of the colposcopy). 4. at the time of colposcopy for workup of a AGC-NOS Pap result (endocervical cells). NOTE: There is nothing to mark on the Sage Enrollment form for this situation, but a sentence should be placed in the Comments area of the form to the effect that an HPV test on an AGC-NOS Pap was \collected with this colposcopy. Also a Sage HPV High Risk DNA Panel form should be sent to Sage with the same encounter Number as the Enrollment form Either the Sage Pap Summary form (if the HPV test is done reflexively on the Pap sample) or the HPV High Risk DNA Panel form is used to report HPV findings to the Sage Screening Program and can be completed by the screening site or by the lab. Alternately, a copy of the report can be sent if the encounter number is added to the report. The following information is required on the form: Sage encounter number, patient name, date specimen collected, lab name (name of facility where HPV was read), specimen number (optional), High Risk DNA Panel interpretation result and the date reported Lab Services - Pathology The Sage Screening Program reimburses for the following services provided by pathologists: Evaluation of abnormal screening Pap smears. Surgical pathology associated with a cervical biopsy done by colposcopy. Endocervical sampling (ECS) obtained by ECC or ECB*. Evaluation of an aspirate obtained through a Fine Needle Aspiration of the breast. Pathology associated with outpatient breast biopsies as described in Section 10. Pathology associated with endometrial biopsies as described in Section 3. 17

19 * If the ECS is sent for cytology, it can only be reimbursed using the CPT codes 88150, 88164, or P3000 and at those rates. If the ECS is sent for histology, it can be billed using the higher reimbursed CPT code Billing and reimbursement This section covers billing and reimbursement from the Sage Screening Program. Provider Agreements: The Sage Screening Program can only reimburse organizations that have a current provider agreement (appendix C1) with the Sage Screening Program. Coordination between Screening Sites and Imaging and Lab Service Providers: Due to the different billing arrangements that imaging and lab providers may have with the Sage Screening Program, it is imperative that screening sites and imaging and lab providers communicate, and establish mutually agreeable billing arrangements. It is recommended that a contact person and phone number at each organization working together to provide Sage Screening Program services be identified, and that an annual or semiannual meeting is held to discuss any issues that may arise. Sage Screening Program staff is always available for assistance in establishing these links or in resolving any problems that may occur. Coordination between Billing and Clinical Staff: Patient results must be received and processed by the Sage Screening Program before payment can be made for services provided. In addition, the patient s encounter number must appear on all billing submissions. Good coordination and communication between billing and clinical staff facilitates resolving any problems that may occur to ensure the timely payment of claims Billing: Basic Requirements Sage Screening Program is considered the payer of last resort, and other sources of payment such as patient insurance should be pursued prior to billing the Sage Screening Program. The provider agrees to accept Sage Screening Program s allowable fee as full payment from all sources (including third party coverage). All Sage Screening Program covered services are free to the patient once she is enrolled in the program. The patient should never be billed for services reimbursable under the Sage Screening Program. The patient should not be charged a co-pay. Claims must be received within 1 year from date of service 14.2 Allowable procedure codes Sage Screening Program will only accept the CPT codes that are relevant to breast or cervical cancer screening and/or diagnostics. When billing for one component of mammography or ultrasound services (i.e., professional or technical), use the appropriate modifier. The provider determines the appropriate office visit level to bill. Note:Sage can only reimburse a level of office visit at a reimbursement level. 18

20 Any CPT code other than those relevant to breast or cervical cancer screening and/or diagnostics will be automatically disallowed Rates Federal law (Public Law ) restricts Sage Program reimbursement rates to the Medicare (CMS) rate for each allowable service (see Sage Screening Program rates are based on the annual CMS Physician Fee Schedule, the CMS Clinical Laboratory Fee Schedule, the Outpatient Prospective Payment System Fee Schedule, and the Ambulatory Surgical Center Fee Schedule. Rates change January 1 of each year, and providers will be notified of the changes. Rates may be updated June 30 th of each year. Note: that Sage can only reimburse a level of office visit at a reimbursement level Submitting claims Sage accepts electronic claims as an ANSI 837 file and using Electronic Data Interchange to submit the claim file. o The designated MDH Sage clearing house is Health-e-Web (HeW). o The Sage Programs Payer Identification is MNDH1. o You must provide the Sage encounter number (or M#) on the 837file as the Subscriber Identifier. o Sage will continue to accept paper claims (see below) for an indeterminate period of time; however, facilities are encouraged to change to electronic claims as soon as possible. Sage Screening Program can also accept claim submission on one of the following: 1. Sage Screening Program Reimbursement and Billing Summary 2. UB CMS-1500 The following items must be listed on these forms Federal Tax ID # of organization to be paid Name of organization to be paid Address of organization to be paid Date of Service Sage Screening Program Encounter Number Patient s Name CPT Code (including modifier, if applicable) Charge for services provided Amount Paid by Insurance (per CPT code), with explanation of benefits (EOB s) attached. Paper claims should be mailed to: Cancer Control Section Minnesota Department of Health 19

21 85 East Seventh Place P.O. Box St. Paul, MN Patients with insurance Insurance should be billed prior to billing the Sage Screening Program. The provider must supply the EOB information in the 837 file or attach a copy of the explanation of benefits (EOB) to a paper claim form submitted to the Sage Screening Program. If insurance pays more than the Sage Screening Program allowable rate, the Sage Screening Program cannot pay the difference and the patient cannot be billed for any portion remaining. Health Savings Accounts (HSAs) are an account with an IRS status for individuals who have high-deductible insurance plans. These are not considered a 3 rd party payor and should not be used to reimburse claims in advance of submission to Sage Payment Claims are processed approximately every two weeks. An electronic transmission of payment should be received shortly after the Sage payment process is completed. Your electronic transmission may contain payment from other programs processed through the State of Minnesota. The payment information can be found at: The Sage Screening Program payments will be clearly marked and contain a Sage payment number as a reference Credits In situations in which an insurance payment is received after Sage has paid your claim, or payment has been made to your organization in error, reimbursement to the Sage Screening Program can be made by Issuing a check payable to Treasurer State of Minnesota: On the stub of the check, please include the date of service, encounter number, patient s name, CPT code, and the amount you received (including the management fee). If more than one encounter number is being reimbursed, either 1) attach a list to the check or 2) highlight the items to be reimbursed on the remittance advice and attach to the check. After this information is processed by the Sage Screening Program, the check will be forwarded to MDH Financial Services for deposit. The check with documentation should be mailed to: Sage Screening Program MDH/Cancer Control Section Central Cashiering-Golden Rule Building PO Box St. Paul, MN Remittance A remittance advice detailing all claims processed is sent: 20