Medicare Compliance & Reimbursement

Know what constitutes 'high risk' patients in CMS's view.

You may have heard that Medicare now reimburses for your physician's work screening for sexually-transmitted diseases, but many practices were unsure of the coverage details. CMS aims to quell any confusion over this issue with a new transmittal that's sure to shed some light on how to collect for these services -- including the issuance of a new G code.

Background: Effective Nov. 8, 2011, Medicare covers screening via lab test for Chlamydia, gonorrhea, syphilis, and hepatitis B when ordered by a primary care provider and performed by a Medicare-eligible provider in high-risk patients. You'll report the appropriate FDA-approved lab testing codes in compliance with CLIA regulations for these tests, said NGS' Medicare's Michelle Poulos during a Feb. 2 NGS webinar discussing Medicare preventive services.

Importantly for Part B practices, CMS also covers high intensity behavior counseling (HIBC) to prevent sexually transmitted infections (STIs) "for all sexually active adolescents and for adults at increased risk for STIs, if referred for this service by a primary care provider and provided by a Medicare-eligible primary care provider in a primary care setting," Transmittal 2402 indicates.

Look to G0445 for This Service

CMS debuted the following new code to describe this counseling service:

• G0445 -- High-intensity behavioral counseling to prevent sexually transmitted infections, face-to-face, individual, includes: education, skills training, and guidance on how to change sexual behavior, performed semi-annually, 30 minutes.

You'll report G0445 with ICD-9 diagnosis code V69.8 (Other problems related to life style), the CMS transmittal states.

HIBC "is defined as a program intended to promote sexual risk reduction or risk avoidance which includes each of these broad topics, allowing flexibility for appropriate patient-focused elements: Education, skills training, and guidance on how to change sexual behavior," CMS says.

Know the 'High Risk' Criteria

• The high/increased risk individual sexual behaviors include any of the following:
• Multiple sex partners
• Using barrier protection inconsistently
• Having sex under the influence of alcohol or drugs
• Having sex in exchange for money or drugs
• Age (24 years of age or younger and sexually active for women for Chlamydia and gonorrhea)
• Having an STI within the past year
• IV drug use (hepatitis B only)
• In addition for men -- men having sex with men (MSM) and engaged in high risk sexual behavior, but no regard to age.

In addition to individual risk factors, physicians should consider community social factors such as high prevalence of STIs in the community populations when determining whether a patient is at high/increased risk for STIs and when recommending HIBC.

"Code G0445 may be paid on the same date of service as an annual wellness visit, evaluation and management code, or during the global billing period for obstetrical care, but only one G0445 may be paid on any one date of service," CMS says in the transmittal. "If billed on the same date of service with an E/M code, the E/M code should have a distinct diagnosis code other than the diagnosis code used to indicate high/increased risk for STIs for the G0445 service. An E/M code should not be billed when the sole reason for the visit is HIBC to prevent STIs."

The medical record should reflect the service provided when the physician performs the HIBC in this patient population, Poulos said.

To read the complete transmittal, visit www.cms.gov/transmittals/downloads/R2402CP.pdf.