Currentblue cross blue shield - michiganPolicy MAPPO 1023

Total body skin examination benefit

Describes Medicare Plus Blue PPO coverage, payment, billing and conditions for one total body skin examination benefit for members, and how it relates to Original Medicare criteria.

Policy Summary

Payerblue cross blue shield - michigan

PolicyTotal body skin examination benefit

Policy CodePolicy MAPPO 1023

Change TypeOperational (billing/coding updates)

Effective Date

Next Review Date

Key ActionBill using appropriate E&M CPT codes with screening diagnosis ICD-10 Z12.83 (or ICD-9 V76.43 for DOS through 9/30/2015) and collect applicable member cost-sharing at time of service when possible.

SourceLink

POLICY UPDATE CHANGES

Updated formatting and billing instructions, removed reference to CAREN, updated web links, added ICD-10 codes.

Once in a lifetimefrequency of covered total body skin exam

Onetotal body skin examination covered under Medicare Plus Blue

Office & outpatientpayable locations

Z12.83required diagnosis code for screening

Lesser of Medicare or charge

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Coverage Criteria

inv-01: Coverage criteria for total body skin examination

Coverage applies as an enhanced Medicare Advantage benefit with conditions and billing requirements as specified below.

Applies to Medicare Plus Blue PPO members (individual and group).

Covered once in a lifetime as an enhanced Medicare Advantage benefit; benefit scope and eligibility consistent with Original Medicare except Original Medicare does not cover routine/asymptomatic total body skin examinations.

Eligibility of service: Total body skin examination is covered when performed as a clinical service related to diagnosis/treatment or as the one allowed enhanced screening benefit under Medicare Plus Blue; examinations solely routine or screening without relation to treatment are not covered under Original Medicare.

Place of service: Payable in office and outpatient hospital settings.

Frequency limit: Once in a lifetime.

ALL of the following

Report Evaluation & Management CPT codes 99201-99205 or 99211-99215; E&M level billed must be supported by documentation available upon request.
Bill with screening diagnosis code ICD-9 V76.43 for dates of service through 9/30/2015 and ICD-10 Z12.83 for dates of service on/after 10/1/2015; report codes to highest specificity.

ALL of the following

Payment equals the lesser of Medicare's allowed amount or the provider's charge, minus the member's cost-share; this payment is considered payment in full and balance billing is not permitted.

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ALL of the following

Submit claims on CMS-1500, UB-04 or 837 format; include NPI and follow Medicare Advantage PPO billing requirements and local Blue Cross submission processes.

ALL of the following

Eligible provider: consistent with Original Medicare (typically trained health care professional such as a dermatologist).

ALL of the following

Use ICD-9 for dates of service through September 30, 2015 and ICD-10 for dates of service beginning October 1, 2015.

Coding and Frequency

Accepted CPT/ICD codesmixedCovered

99201-99205, 99211-99215	Evaluation and Management codes for total body skin examination (E&M level must be supported by documentation)
ICD-9 V76.43	Special screening for malignant neoplasms, skin (DOS through 9/30/2015)
ICD-10 Z12.83	Special screening for malignant neoplasm of skin (DOS beginning 10/1/2015)

inv-03: Frequency limit

Frequency limitOnce in a lifetime

Payable locationsOffice and outpatient hospital

Eligible providerConsistent with Original Medicare

Age restrictionsConsistent with Original Medicare

Provider Actions, Documentation, and Cost-share

Documentation Required

Prior authorization / documentation and cost-share collection

Documentation must be available to support the level of E&M service billed. Use the appropriate E&M CPT codes (99201-99205, 99211-99215) and bill with the screening diagnosis code ICD-9 V76.43 for dates of service through 9/30/2015 or ICD-10 Z12.83 for dates of service beginning 10/1/2015. Collect applicable Medicare Plus Blue cost-sharing from the member at the time of service when possible and verify benefits/cost-share via web‑DENIS or 1‑866‑309‑1719.

Use E&M codes 99201-99205 or 99211-99215 and ensure documentation supports the E&M level billed.
Bill with ICD-9 V76.43 (DOS through 9/30/2015) or ICD-10 Z12.83 (DOS on/after 10/1/2015).
Collect appropriate Medicare Plus Blue copayment/coinsurance/deductible at time of service when possible.
Verify member benefits and cost-share via web-DENIS or by calling 1-866-309-1719.

Definitions

inv-05: Total body skin examination

DefinitionA total body skin examination is performed by a trained health care professional to search for any unusual or suspicious lesions or conditions over the entire skin surface, including hands, arms, legs, feet, torso, scalp, inside of the mouth and the external genital area.

PurposeTo detect atypical or abnormal moles and other lesions that could represent melanoma or other skin cancers.

Typical providerUsually a dermatologist or other trained health care professional.

Scope of examExamines the entire skin surface; melanoma can arise on any part of the skin, even areas not exposed to the sun.