• G0442 - Annual alcohol misuse screening, 15 minutes
• G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

• G0442 - Annually
• G0443 - For those who screen positive, four times per year

Screening: All Medicare beneficiaries are eligible

Counseling: Beneficiaries who screen positive are eligible if:

• They are competent and alert at the time counseling is provided; and
• Counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting

Counseling is to be completed based on Five As Approach

1. Assess: Ask about or assess behavioral health risks and factors affecting choice of behavior change goals/methods.
2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient's interest in and willingness to change the behavior.
4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

• CMS Internet Only Manual (IOM), Publication 100-04, Chapter 18, Section 180
• CMS National Coverage Determination (NCD) 210.8
• CMS Preventive Services FAQ

• G0438 - Initial visit
• G0439 - Subsequent visit

• G0438 - Once in a lifetime
• G0439 - Annually

• Beneficiary not within 12 months after effective date of their first Medicare Part B coverage period
• Has not received Initial Preventive Physical Examination (IPPE) or AWV within past 12 months
• Performed by health professional:
  • Physician
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Medical professional (including health educator, registered dietitian, nutrition professional or other licensed practitioner) or team of such medical professionals, working under direct supervision of physician

Copayment/coinsurance waived; Deductible waived

• Annual Wellness Visit Educational Tool
• IPPE and AWV
• CMS IOM, Publication 100-02, Chapter 15, Section 280.5
• CMS IOM, Publication 100-04, Chapter 18, Section 140
• CMS Preventive Services FAQ
• 42 CFR 410.15(a)
• MLN Matters® Article SE18004, Review of Opioid Use During the IPPE and the AWV

• 76977 - Ultrasound bone density measurement and interpretation, peripheral site(s), any method
• 77078 - Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
• 77080 - Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
• 77081 - DXA, bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
• 77085 - DXA, bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment
• G0130 - Single energy X-ray absorptiometry (SEXA) bone density study, one or more sites, appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

Beneficiary must fall into one of the following categories:

• Women determined by physician or qualified non-physician practitioner to be estrogen deficient and at clinical risk for osteoporosis
• Individuals with vertebral abnormalities
• Individuals getting (or expecting to get) glucocorticoid therapy for more than three months
• Individuals with primary hyperparathyroidism
• Individuals being monitored to assess response to U.S. Food and Drug Administration (FDA)-approved osteoporosis drug therapy

• CMS IOM, Publication 100-02, Chapter 15, Section 80.5
• CMS Preventive Services FAQ

• 80061 - Lipid panel, this panel must include:
  • 82465 - Cholesterol, serum, total
  • 83718 - Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
  • 84478 - Triglycerides

Z13.6 - Encounter for screening for cardiovascular disorders

• Cardiology
• CMS IOM, Publication 100-04, Chapter 18, Section 100
• CMS Preventive Services FAQ

G0476 - Cervical cancer screening, all-inclusive HPV co-test with cytology (Pap smear)

• Z11.51 - Encounter for screening for human papillomavirus; and
  • Z01.411 - Encounter for gynecological examination (general) (routine) with abnormal findings; or
  • Z01.419 - Encounter for gynecological examination (general) (routine) without abnormal findings

• Female beneficiaries aged 30 - 65 years
• Asymptomatic

• CMS IOM, Publication 100-04, Chapter 18, Section 30.2.1
• CMS NCD 210.2.1
• CMS Preventive Services FAQ
• CMS Screening Pap Tests and Pelvic Examinations

CPT and HCPCS:

• 82270 - Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (e.g., patient was provided three cards or single triple card for consecutive collection)
• G0328 - Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous

Frequency: Once every 12 months

82270 may be billed in place of G0328; however, both cannot be performed in same 12-month period

Coverage:

• Aged 45 and older at normal risk for developing colorectal cancer; or
• At high risk for developing colorectal cancer

Payment: Copayment/coinsurance waived; Deductible waived

CPT: 81528 - Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result

Frequency: Once every three years

Diagnosis:

• Z12.11 - Encounter for screening for malignant neoplasm of colon; and
• Z12.12 - Encounter for screening for malignant neoplasm of rectum

Coverage:

• Aged 45 and older
• Asymptomatic
• At average risk of developing colorectal cancer

Payment: Copayment/coinsurance waived; Deductible waived

HCPCS: G0104 - Flexible Sigmoidoscopy

Frequency:

• High risk: Once every 48 months
• Not high risk: Once every 48 months (unless beneficiary does not meet criteria for high risk of developing colorectal cancer and beneficiary has had screening colonoscopy (G0121) within previous 10 years, screening flexible sigmoidoscopy is covered only after at least 119 months have passed following the month he/she received the G0121)

Coverage:

• Aged 45 and older at normal risk for developing colorectal cancer; or
• At high risk for developing colorectal cancer

Payment: Copayment/coinsurance waived; Deductible waived

• If screening turns to diagnostic with PT modifier appended, special coinsurance percentage phase-in; Calendar Year (CY):

• • CY 2023-2026, coinsurance 15%
  • CY 2027-2029, coinsurance 10%
  • Beginning CY 2030 and beyond, no coinsurance

HCPCS:

• G0105 - Colonoscopy (high risk)
• G0121 - Colonoscopy (not high risk)

Frequency:

• High risk: Once every 24 months (unless screening flexible sigmoidoscopy was performed, then covered only after at least 47 months)
• Not high risk: Once every 10 years or 48 months after previous sigmoidoscopy

Payment: Copayment/coinsurance waived; Deductible waived

• If screening turns to diagnostic with PT modifier appended, special coinsurance percentage phase-in; Calendar Year (CY):

• • CY 2023-2026, coinsurance 15%
  • CY 2027-2029, coinsurance 10%
  • Beginning CY 2030 and beyond, no coinsurance

Medicare does not specifically state whether a colonoscopy for "Surveillance" purposes is considered screening or diagnostic exclusively. Rather, it depends on the colonoscopy determination of billing:

• Procedure reason and clinical circumstances

Example:

• Patient has personal history of polyps and meets characteristics of high-risk individual
• Physician states "surveillance" for next colonoscopy
  • Could be considered high-risk screening utilizing HCPCS G0105
• Colonoscopy performed at three years and falls within interval timeframe for Medicare reimbursement

When a screening colonoscopy (routine or high-risk screening) procedure becomes more consistent with a diagnostic colonoscopy (based on findings, biopsy, additional required intervention, etc.), the coding will change to a diagnostic procedure. Append -PT modifier to signify the intraprocedural status change.

HCPCS:

• G0106 - Barium Enema (alternative to G0104)
• G0120 - Barium Enema (alternative to G0105)

Frequency:

• High risk: Once every 24 months (when used instead of flexible sigmoidoscopy or colonoscopy)
• Not high risk: Once every 48 months (when used instead of flexible sigmoidoscopy or colonoscopy)

Coverage:

• Aged 45 and older at normal risk for developing colorectal cancer; or
• At high risk for developing colorectal cancer

Payment: Copayment/coinsurance applies; Deductible waived

• Close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
• Family history of familial adenomatous polyposis
• Family history of hereditary nonpolyposis colorectal cancer
• Personal history of adenomatous polyps
• Personal history of colorectal cancer
• Personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis

• Use diagnostic CPT/HCPCS code
• Primary diagnosis is screening; Secondary diagnosis indicates abnormal finding
  • Link second diagnosis to diagnostic code
• Append modifier PT to indicate screening turned diagnostic
• If screening turns to diagnostic with PT modifier appended, special coinsurance percentage phase-in; Calendar Year (CY):
  • CY 2023-2026, coinsurance 15%
  • CY 2027-2029, coinsurance 10%
  • Beginning CY 2030 and beyond, no coinsurance
• Laboratory services associated with a diagnostic colonoscopy should bill an appropriate diagnosis that does not indicate screening. Modifiers PT and 33 are not used for lab or pathology services

• When a colonoscopy becomes diagnostic, anesthesia is reported using CPT 00811 with modifier PT. Bill with diagnostic CPT code (453xx series) and deductible only is waived
• CPT 00812 (with no modifier) is used with screening codes. Both coinsurance and deductible are waived
• Do not append modifier PT to other anesthesia CPTs 00730, 00740 and 00813
• Modifier 33 is not recognized for any colonoscopy/anesthesia codes

• Use modifier 53 to indicate a colonoscopy cannot be completed due to unforeseen circumstances. Billed amount must also be reduced upon claim submission. Medicare allows one-half the value of code billed
• If a procedure is cancelled before any prep was completed, this cannot be billed for
• Ambulatory Surgical Centers must append modifier 73 or 74 to indicate discontinued procedure prior to/after anesthesia administration

Example 1:

• Dr. A referred a beneficiary for a screening colonoscopy. Since beneficiary is new to Dr. B, he/she would like to bill for an E/M visit and colonoscopy
• If colonoscopy is performed same day as E/M, E/M is bundled into colonoscopy. E/M is not a separate, identifiable service. Beneficiary was evaluated by Dr. A before being sent to Dr. B. A second opinion or decision is not being requested, only the colonoscopy

Example 2:

• Dr. A referred a beneficiary for a screening colonoscopy. On that day, beneficiary complained about stomach pain and loose, bloody stool so Dr. B did a full exam first
• In this case, a new patient visit may be billed. Modifier 25 is not required on new patient visits

• CMS IOM, Publication 100-02, Chapter 15, Section 280.2
• CMS IOM, Publication 100-04, Chapter 18, Section 60
• CMS National Coverage Determination (NCD) 210.3
• CMS Preventive Services FAQ
• CMS MLN Matters (MM) 12656 - Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter As Certain Colorectal Cancer Screening Tests
• CMS MM 13017 - Removal of a National Coverage Determination & Expansion of Coverage of Colorectal Cancer Screening

• 99406 - Smoking and tobacco-use cessation counseling visit; intermediate, greater than three minutes up to 10 minutes
• 99407 - Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes

• F17.210 - Nicotine dependence, cigarettes, uncomplicated
• F17.211 - Nicotine dependence, cigarettes, in remission
• F17.213 - Nicotine dependence, cigarettes, with withdrawal
• F17.218 - Nicotine dependence, cigarettes, with other nicotine-induced disorders
• F17.219 - Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders
• F17.220 - Nicotine dependence, chewing tobacco, uncomplicated
• F17.221 - Nicotine dependence, chewing tobacco, in remission
• F17.223 - Nicotine dependence, chewing tobacco, with withdrawal
• F17.228 - Nicotine dependence, chewing tobacco, with other nicotine-induced disorders
• F17.229 - Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders
• F17.290 - Nicotine dependence, other tobacco product, uncomplicated
• F17.291 - Nicotine dependence, other tobacco product, in remission
• F17.293 - Nicotine dependence, other tobacco product, with withdrawal
• F17.298 - Nicotine dependence, other tobacco product, with other nicotine-induced disorders
• F17.299 - Nicotine dependence, other tobacco product, with unspecified nicotine-induced disorders
• T65.211A - Toxic effect of chewing tobacco, accidental (unintentional), initial encounter
• T65.212A - Toxic effect of chewing tobacco, intentional self-harm, initial encounter
• T65.213A - Toxic effect of chewing tobacco, assault, initial encounter
• T65.214A - Toxic effect of chewing tobacco, undetermined, initial encounter
• T65.221A - Toxic effect of tobacco cigarettes, accidental (unintentional), initial encounter
• T65.222A - Toxic effect of tobacco cigarettes, intentional self-harm, initial encounter
• T65.223A - Toxic effect of tobacco cigarettes, assault, initial encounter
• T65.224A - Toxic effect of tobacco cigarettes, undetermined, initial encounter
• T65.291A - Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter
• T65.292A - Toxic effect of other tobacco and nicotine, intentional self-harm, initial encounter
• T65.293A - Toxic effect of other tobacco and nicotine, assault, initial encounter
• T65.294A - Toxic effect of other tobacco and nicotine, undetermined, initial encounter; or
• Z87.891 - Personal history of nicotine dependence, unspecified, uncomplicated

Outpatient and hospitalized beneficiaries who meet all of the following:

• Use tobacco
• Competent and alert at time of counseling
• Counseling furnished by qualified physician or other Medicare-recognized practitioner

• CMS IOM, Publication 100-04, Chapter 18, Section 150
• CMS NCD 210.4
• CMS Preventive Services FAQ

AstraZeneca

• M0220 - Injection, tixagevimab and cilgavimab, for pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection and most administration monitoring
• M0221 - Injection, tixagevimab and cilgavimab, for pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency
• Q0220 - Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 300 mg (EVUSHELD)
• Q0221 - Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 300 mg (EVUSHELD); repeat dosing every six months for patients needing ongoing protection in healthcare settings or in the home (M0220 and M0221, respectively)

Eli Lilly

• M0222 - Intravenous injection, includes injection and post administration monitoring
• M0223 - Intravenous injection, includes injection and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency
• M0239 - Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring
• Q0222 - Injection, bebtelovimab, 175 mg
• Q0239 - Injection, bamlanivimab-xxxx, 700 mg

Genentech

• M0249 - Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose.
• M0250 - Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose.
• Q0249 - Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg.

GSK

• M0247 - Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
• M0248 - Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency.
• Q0247 - Injection, sotrovimab, 500 mg

Janssen

• 0031A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (ad26) vector, preservative free, 5x10^10 viral particles/0.5mL dosage, single dose
• 0034A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5 mL dosage; booster dose
• 91303 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x10^10 viral particles/0.5 mL dosage, for intramuscular use
• M0201 - COVID-19 vaccine administration inside a patient's home; reported only once per individual home per date of service when only COVID-19 vaccine administration is performed at the patient's home.

Moderna

• 0011A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, diluent reconstituted; first dose
• 0012A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, diluent reconstituted; second dose
• 0013A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose
• 0064A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, booster dose vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, for intramuscular use
• 0091A - Immunization administration (91309 vaccine) for pediatric patients ages 6 years through 11 years; first dose
• 0092A - Immunization administration (91309 vaccine) for pediatric patients age 6 years through 11 years; second dose
• 0093A - Immunization administration (91309 vaccine) for pediatric patients ages 6 years through 11 years; third dose
• 0094A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.5 mL dosage, booster dose; individuals 18 years and over
• 0111A - Immunization administration (91311 vaccine) for pediatric patients ages 6 months through 5 years; first dose
• 0112A - Immunization administration (91311 vaccine) for pediatric patients ages 6 months through 5 years; second dose
• 0113A - Immunization administration (91311 vaccine) for pediatric patients ages 6 months through 5 years; third dose
• 0134A - Immunization administration (91313 vaccine); booster dose for ages 18 years and older (after 8/31/2022)
• 0144A - Immunization administration (91314 vaccine); booster for ages 6 years through 11 years (after 10/12/22)
• 0164A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 10 mcg/0.2 mL dosage, booster dose
• 91301 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, diluent reconstituted, for intramuscular use
• 91306 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, for intramuscular use
• 91309 - severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use
• 91311 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use
• 91313 - severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use; booster for ages 18 years and older (after 8/31/2022)
• 91314 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use; booster for ages 6 years through 11 years (after 10/12/22)
• 91316 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 10 mcg/0.2mL dosage, for intramuscular use; pediatric six months for ages 6 months through 5 years (after 12/08/2022)

Novavax

• 0041A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5 mL dosage; first dose (7/13/22)
• 0042A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5 mL dosage; second dose (7/13/22)
• 0044A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; booster dose
• 91304 - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5 mL dosage, for intramuscular use (7/13/22)

Pfizer-BioNTech

• 0001A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose
• 0002A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose
• 0003A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose
• 0004A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted: booster dose
• 0051A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; first dose
  • 0052A second dose
  • 0053A third dose
  • 0054A booster dose
• 0071A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose
• 0072A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose
• 0073A - Immunization administration by intramuscular inject of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 10 mcg/0.2mL dosage, diluent, reconstituted, tri-sucrose formulation; third dose
• 0074A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; booster dose
• 0081A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose (after 6/17/22)
• 0082A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose (after 6/17/22)
• 0083A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; third dose (after 6/17/22)
• 0124A - Immunization administration (91312 vaccine); booster dose for ages 12 years and older (after 8/31/2022)
• 0154A - Immunization administration (91315 vaccine) by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, booster dose for ages 5 years through 11 years (after 10/12/22)
• 0173A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, third dose
• 91300 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use
• 91305 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use
• 91307 - Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
• 91308 - severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID19]) vaccine, mRNALNP, spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use; pediatric ages six months through four years (after 6/17/2022)
• 91312 - severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use; booster for ages 12 years and older (after 8/31/2022)
• 91315 - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use; booster for ages 5 years through 11 years (after 10/12/22)
• 91317 - Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use; third primary series does for ages 6 months through 4 years (after 12/08/2022)

Regeneron

• M0240 - Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses
• M0241 - Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency, subsequent repeat doses
• M0243 - Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring (Regeneron)
• M0244 - Intravenous infusion, casirivimab and imdevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency
• M0245 - Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
• M0246 - Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency
• Q0240 - Injection, casirivimab and imdevimab, 600 mg
• Q0243 - Injection, casirivimab and imdevimab, 2400mg (Regeneron)
• Q0245 - Injection, bamlanivimab and etesevimab, 2100 mg

• All Medicare beneficiaries
• Original Medicare no longer pays COVID-19 vaccine or monoclonal antibody product administration claims for Medicare Advantage beneficiaries on or after January 1, 2022, unless the beneficiary in a Medicare Advantage plan has chosen to enroll in hospice.

Copayment/coinsurance waived; Deductible waived

For a COVID-19 vaccine administration service the national payment rate is $40.00. MACs will apply geographically adjusted rates for payment purposes. For payment rates for COVID-19 vaccine administration, visit the COVID-19 Vaccines and Monoclonal Antibodies webpage on CMS.

Payment for monoclonal antibody administration will be $309.60 (geographically adjusted to state/locality). Providers should not bill for the product if they received it for free. For more information on the monoclonal antibodies and their administration, visit the COVID-19 Vaccines and Monoclonal Antibodies webpage on CMS.

• CDC COVID-19 Vaccination Communication Toolkit for medical centers, clinics, and clinicians
• CMS COVID-19 FAQs (PDF):
• CMS COVID-19 Provider Toolkit
• CMS COVID-19 Vaccine Administration
• CMS COVID-19 Vaccines and Monoclonal Antibodies Payment Allowances and Effective Dates
• CMS Monoclonal Antibody COVID-19 Infusion
• CMS Office of Minority Health COVID-19 Resources on Vulnerable Populations
• Healthcare System Cybersecurity: Readiness & Response Considerations
• FDA COVID-19 Vaccines
• PC-ACE Software

G0444 - Annual depression screening, 15 minutes

• All Medicare beneficiaries are eligible
• Must be furnished in primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up

Coverage is limited to screening services and does not include treatment options for depression or any diseases, complications, or chronic conditions resulting from depression, nor does it address therapeutic interventions such as pharmacotherapy, combination therapy (counseling and medications), or other interventions for depression

Depression Screening cannot be done the same time as the initial AWV or Initial Preventive Physical Exam (IPPE)

Copayment/coinsurance waived; Deductible waived

• CMS IOM, Publication 100-04, Chapter 18, Section 190
• CMS NCD 210.9
• CMS Preventive Services FAQ

• 82947 - Glucose; quantitative, blood
• 82950 - Glucose; post glucose dose
• 82951 - Glucose; tolerance test, three specimens

Beneficiaries diagnosed with pre-diabetes: Two screening tests per year

• Use modifier TS to indicate beneficiary is pre-diabetic

Beneficiaries previously tested by not diagnosed with pre-diabetes or never tested: One screening per year

Z13.1 - Encounter for screening for diabetes mellitus

Medicare beneficiaries with certain risk factors or diagnosed with pre-diabetes

Risk factors:

• Any one:
  • Hypertension
  • Dyslipidemia
  • Obesity
  • Previous identification of elevated impaired fasting glucose or glucose tolerance
• Any two:
  • Overweight
  • Family history
  • Age 65 or older
  • History of gestational diabetes mellitus or delivering baby weighing over nine pounds

• Medicare Diabetes Prevention Program (MDPP)
• CMS IOM, Publication 100-04, Chapter 18, Section 90
• CMS Preventive Services FAQ

• G0108 - DSMT, individual, per 30 minutes
• G0109 - DSMT, group (two or more people), per 30 minutes

Beneficiary must meet both of the following:

• Diagnosed with diabetes
• Receive order for DSMT from physician or qualified non-physician practitioner treating beneficiary's diabetes

• DSMT and Medical Nutrition Therapy (MNT) Services
• CMS IOM, Publication 100-02, Chapter 15, Section 300
• CMS IOM, Publication 100-04, Chapter 18, Section 120
• CMS NCD 180.1
• CMS Preventive Services FAQ

• G0117 - By optometrist or ophthalmologist
• G0118 - Under direct supervision of optometrist or ophthalmologist

Z13.5 - Encounter for screening for eye and ear disorders

Must fall into one category:

• Have diabetes mellitus
• Have family history of glaucoma
• African-Americans aged 50 and older
• Hispanic-Americans aged 65 and older

Medicare will pay for glaucoma screening examinations where they are furnished by or under direct supervision in office setting of an ophthalmologist or optometrist, who is legally authorized to perform services under State law

Screening for glaucoma is defined to include:

• A dilated eye examination with an intraocular pressure measurement; and
• A direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination

• CMS IOM, Publication 100-02, Chapter 15, Section 280.1
• CMS IOM, Publication 100-04, Chapter 18, Section 70
• CMS Preventive Services FAQ

• 90739 - Hepatitis B vaccine, adult dosage (two dose schedule), for intramuscular use
• 90740 - Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (three dose schedule), for intramuscular use
• 90743 - Hepatitis B vaccine, adolescent (two dose schedule), for intramuscular use
• 90744 - Hepatitis B vaccine, pediatric/adolescent dosage (three dose schedule), for intramuscular use
• 90746 - Hepatitis B vaccine, adult dosage (three dose schedule), for intramuscular use
• 90747 - Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (four dose schedule), for intramuscular use
• 90759 - Hepatitis B vaccine, 3-antigen, 10 mcg dosage (3 dose schedule), for intramuscular use
• G0010 - Administration of Hepatitis B vaccine

Z23 - Encounter for immunization

Intermediate risk

• Staff at institutions for mentally challenged
• Workers who have frequent contact with blood or blood-derived body fluids

High risk

• End Stage Renal Disease (ESRD) patients
• Clients of institutions for mentally challenged
• Someone who lives in same house as a hepatitis b virus carrier
• Homosexual men
• Someone who injects illicit drugs

Medicare beneficiaries currently positive for antibodies for hepatitis B are not eligible for this benefit

Copayment/coinsurance waived; Deductible waived

G0010 allows $30 (2022)

• CMS IOM, Publication 100-02, Chapter 15, Section 50.4.4.2
• CMS IOM, Publication 100-04, Chapter 18, Section 10
• CMS Preventive Services FAQ

G0472 - Hepatitis C antibody screening, for individual at high risk and other covered indication(s)

• Annually only for high risk beneficiaries with continued illicit injection drug use since prior negative screening test
• Once in a lifetime for beneficiaries born between 1945 and 1965 who are not considered high risk
• Initial screening, regardless of birth year, who had a blood transfusion before 1992 and beneficiaries with current or past history of illicit injection drug use

Initially high-risk

• Z72.89 - Other problems related to lifestyle

High risk with continued illicit injection drug use since prior screening

• Z72.89 - Other problems related to lifestyle; and
• F19.20 - Other psychoactive substance dependence, uncomplicated

• Ordered by primary care physician or practitioner; and
• Beneficiary must be either be:
  • High risk for HCV infection
    • Persons with current or past history of illicit injection drug use
    • History of receiving blood transfusion prior to 1992
  • Born between 1945 and 1965

• CMS IOM, Publication 100-04, Chapter 18, Section 210
• CMS Medicare Learning Network (MLN) Matters (MM)8871
• CMS NCD 210.13
• CMS Preventive Services FAQ

• 80081 - Obstetric panel (includes HIV testing)
• G0432 - Infectious agent antibody detection by enzyme immunoassay (EIA) technique
• G0433 - Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique
• G0435 - Infectious agent antibody detection by rapid antibody test
• G0475 - HIV antigen/antibody, combination assay, screening

• Annually for beneficiaries between 15 - 65 years without regard to perceived risk
• Annually for beneficiaries under 15 years and adults older than 65 who are at increased risk for HIV infection:
  • Men who have sex with men
  • Men and women having unprotected vaginal or anal intercourse
  • Past of present injection drug users
  • Men and women who exchange sex for money or drugs or have sex partners who do
  • Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users,
  • Persons who have acquired or request testing for other sexually transmitted infectious diseases,
  • Persons with a history of blood transfusions between 1978 and 1985,
  • Persons who request an HIV test despite reporting no individual risk factors,
  • Persons with new sexual partners,
  • Persons who, based on individualized physician interview and examination

• Pregnant beneficiaries covered three times during pregnancy
  • When diagnosed as pregnant
  • During third trimester
  • At labor, if ordered by clinician

Increased risk factors not reported

• Z11.4 - Encounter for screening for human immunodeficiency virus

Increased risk factors reported

• Z11.4 - Encounter for screening for human immunodeficiency virus; and
• Z72.89 - Other problems related to lifestyle
• Z72.51 - High risk heterosexual behavior
• Z72.52 - High risk homosexual behavior; or
• Z72.53 - High risk bisexual behavior

Pregnant Medicare beneficiaries

• Z11.4 - Encounter for screening for human immunodeficiency virus; and
• Z34.00 - Encounter for supervision of normal first pregnancy, unspecified trimester
• Z34.01 - Encounter for supervision of normal first pregnancy, first trimester
• Z34.02 - Encounter for supervision of normal first pregnancy, second trimester
• Z34.03 - Encounter for supervision of normal first pregnancy, third trimester
• Z34.80 - Encounter for supervision of other normal pregnancy, unspecified trimester
• Z34.81 - Encounter for supervision of other normal pregnancy, first trimester
• Z34.82 - Encounter for supervision of other normal pregnancy, second trimester
• Z34.83 - Encounter for supervision of other normal pregnancy, third trimester
• Z34.90 - Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
• Z34.91 - Encounter for supervision of normal pregnancy, unspecified, first trimester
• Z34.92 - Encounter for supervision of normal pregnancy, unspecified, second trimester
• Z34.93 - Encounter for supervision of normal pregnancy, unspecified, third trimester
• O09.90 - Supervision of high risk pregnancy, unspecified, unspecified trimester
• O09.91 - Supervision of high risk pregnancy, unspecified, first trimester
• O09.92 - Supervision of high risk pregnancy, unspecified, second trimester; or
• O09.93 - Supervision of high risk pregnancy, unspecified, third trimester

Beneficiaries must meet one of the following:

• Beneficiaries at increased risk for HIV infection
• Anyone who asks for test
• Pregnant women

Noncoverage

• Beneficiary with any known diagnosis of HIV-related illness
• Beneficiary who has had screening within one year
• Pregnant beneficiary who has had three specified screening tests within each respective term of pregnancy

• CMS IOM, Publication 100-04, Chapter 18, Section 130
• CMS NCD 210.7
• CMS Preventive Services FAQ