CurrentHawaii Medical Service Association (HMSA)Policy N/A

Chapter 18 — Preventive and Screening Services (Medicare): Coverage, Billing, and Payment

Governs Medicare coverage, billing, and payment policies for a wide range of preventive and screening services (vaccines, screenings, wellness visits, counseling, and related billing rules) affecting Medicare contractors, providers, suppliers, and beneficiaries.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyChapter 18 — Preventive and Screening Services (Medicare): Coverage, Billing, and Payment

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnroll as a Mass Immunization Roster Biller via CMS-855 and, if centralized billing is used, register with the designated Part B MAC and accept assignment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Ch. 18Chapter

4 vaccinesVaccines covered

100% paymentPayment for listed vaccines

Table of servicesPrEP entries

5Roster billing minimum

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Billing Criteria

Coverage and billing stance

Coverage stance and key coverage/payment rules presented in this Part:

Medicare pays 100% of the Medicare allowed amount under Part B for pneumococcal, influenza, hepatitis B, and COVID-19 vaccines and their administration; Part B deductible and coinsurance do not apply.

Coinsurance and copayment are waived for preventive services recommended by the USPSTF with a grade of A or B and for the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) as specified by statute.

Deductible is waived for preventive services with USPSTF A or B grades and for IPPE/AWV effective as described in this chapter.

Providers must follow detailed HCPCS, diagnosis, TOB, revenue code, and Common Working File (CWF) edits and payment rules for each preventive service as outlined in the chapter sections and tables.

Coverage and payment criteria summary

Medicare covers influenza, pneumococcal, hepatitis B, and COVID-19 vaccines and their administration under the vaccine benefit with specified payment rules by provider type and claim type.

Covered vaccines: influenza, pneumococcal, hepatitis B, and COVID-19; vaccine product payment follows Medicare drug/biological reimbursement methods and administration payment follows MPFS-based rates.

Vaccine product payment to freestanding renal dialysis facilities is the lower of actual charge or 95% of AWP; hospital-based facilities and provider-based RDFs follow reasonable cost rules.

All providers must accept assignment for vaccine products (mandatory assignment). Administration assignment is not mandatory except for roster/centralized billers; administration national rates include G0008/G0009/G0010 national rate $30 (Jan 1, 2022) locality-adjusted, and COVID-19 administration $40 during the PHE period (locality-adjusted).

MACs should apply locality-adjusted MPFS payment methods for administration and follow claim-type-specific payment rules (OPPS, MPFS, CLFS, reasonable cost) depending on setting.

No-billing scenarios

Billing restrictions based on free-immunization policies

Nongovernmental entities that provide immunizations free of charge to all patients may not bill Medicare for those vaccines; governmental entities may bill when services are free to non‑Medicare beneficiaries, except during public health emergencies when vaccines are provided at no charge to all.

Roster and centralized billing coverage criteria

Conditions and required data to submit roster claims for covered vaccines:

Roster billing is allowed for influenza, pneumococcal, COVID-19, and (effective Jan 1, 2025) hepatitis B vaccinations when submitted using the simplified roster claims process.

Entities using roster billing must accept assignment and may not collect any payment, donation, or other cost sharing from beneficiaries; charges for each listed service on the cover CMS-1500 must reflect actual charge or $0.00/NC when no charge.

Use a modified Form CMS-1500 as the cover document with POS code 60 for roster billing and include vaccine and administration codes in Item 24D; attach a roster containing at minimum provider name/number, date of service, control number, beneficiary MBI, name, address, DOB, sex, and signature (or 'signature on file').

MACs will create individual claims per beneficiary from the roster and process per payment locality; MACs may supplement missing CMS-1500 fields from roster when possible but will return claims as unprocessable if required fields are absent per roster rules.

Centralized and roster billing criteria and processing rules

Criteria and procedural requirements for entities to qualify and maintain centralized billing privileges and for roster billing eligibility

Geographic scope: to qualify as a centralized biller, the entity must provide immunization services in at least three payment localities processed by at least three different contractors.

Licensure: entities must be properly licensed in the states where immunizations are administered.

Assignment and beneficiary billing prohibition: centralized billers must accept assignment and may not charge beneficiaries or require them to file claims; beneficiaries must be provided written notice of the processing Part B MAC at time of vaccination.

Claim submission format: centralized billers must submit roster claims electronically in approved formats; paper claims will not be accepted for centralized billers.

Beneficiary data requirements: centralized billers must collect and include beneficiary name, MBI, DOB, sex, address, and signature on the roster to permit MSNs and proper processing.

Duplicate payment prevention edits (vaccines)

CWF duplicate-payment edit criteria for influenza and pneumococcal vaccines and administration codes

CWF edits prevent duplicate payment by matching MBI, MAC number (or different MAC under specified cross‑edits), date of service, and listed vaccine HCPCS/procedure or administration codes; when a matching prior line exists, CWF rejects the second claim.

Match rules

If same MBI, same MAC (Part A or B), same date of service, and either any listed influenza HCPCS or matching pneumococcal HCPCS (as specified), then the second claim rejects.
If same MBI, different MAC (Part B centralized vs local) and same date of service and same HCPCS as listed, the second claim rejects under crossover edit rules.
Administration codes (G0008/G0009) reject when same MBI, same MAC number, same date of service, and same procedure code match an existing record.

Mammography coverage and billing

Mammography coverage and billing criteria

Only FDA‑certified mammography facilities (MQSA certificate) are reimbursed for screening and diagnostic mammography; contractors must validate the facility's FDA 6‑digit certification number against the MQSA file and deny or return claims when missing or mismatched.

Screening mammography must be billed with the appropriate HCPCS/CPT codes (e.g., CPT 77067 for bilateral screening; CPT 77063 for tomosynthesis add‑on) and the screening diagnosis code Z12.31 when applicable; claims lacking required diagnosis or certification data are returned unprocessable or denied per MAC rules.

When a screening converts to diagnostic on the same day, append modifier -GG to the diagnostic mammography code and bill both screening and diagnostic tests; both may be reimbursed for data collection/tracking.

Coverage and payment criteria for mammography services

General payment principles for screening mammography under MPFS and A/B MACs:

Payment for screening mammography in many settings equals the lower of the provider's actual charge or the locality‑specific MPFS technical component amount; Part B deductible is waived for screening mammography in many settings though coinsurance may apply depending on provider type.

A/B MAC (B) pays physicians and suppliers under the MPFS where Medicare payment equals 80% of the allowed charge and coinsurance 20%; Part B deductible for screening mammography is waived.

Outpatient hospital screening mammography payment is the lesser of charge or technical component of MPFS for CPT/HCPCS screening code; diagnostic mammography payments and deductible/coinsurance treatment vary by setting and code.

Mammography coverage criteria

Coverage and denial criteria for screening and diagnostic mammography claims.

Age restrictions: screening mammography is not covered for women under age 35; one screening is covered for women age 35-39; screening mammograms are covered annually for women age 40 and older.

Frequency and interval: deny screening mammography if performed before the required interval has elapsed (e.g., less than 12 months) and use the specified MSN denial messages (e.g., MSN 18.4 for interval denials, MSN 18.6 for age 35-39 one‑time coverage, MSN 18.12 for annual coverage 40+).

Facility certification and claim completeness: claims missing the facility's FDA 6‑digit certification number or with nonmatching certification shall be returned unprocessable or denied; film/digital indicators must match facility certification.

Same‑day screening to diagnostic conversion: when screening converts to diagnostic on the same day, append modifier -GG to the diagnostic code and bill both codes; both reimbursable per tracking guidance.

Screening mammography and Pap smear coverage rules

Key coverage and billing rules extracted from the document portion:

Screening mammography: covered once for women age 35-39.

Screening mammography: covered annually for women age 40 and older.

Deny when interval requirements have not been met; use MSN 18.4 and appropriate CARC/RARC for remittance advice when applicable.

Deny if provider/facility lacks appropriate MQSA/FDA certification; use MSN 16.2 and remittance advice CARC/RARC codes for invalid or missing certification.

HPV co-testing (HCPCS G0476) is allowed once every 5 years for asymptomatic beneficiaries age 30-65 when performed with Pap and must be billed with POS 81 or 11.

Coverage and billing criteria (Pap smear & HPV)

Medicare coverage frequency and diagnosis requirements for screening Pap smears and HPV co-testing

Frequency rules

Low‑risk beneficiaries: screening Pap smear paid every 2 years.
High‑risk beneficiaries: screening Pap smear paid every year (once every 11 months when high‑risk criteria met).

Diagnosis and claim pointing requirement: claims must include an applicable low‑risk or high‑risk ICD‑10‑CM diagnosis code in the claim (Item 21/Form CMS‑1500) and point to that diagnosis in Item 24E or electronic equivalent; otherwise CWF will reject the claim.

HPV co‑testing (HCPCS G0476) requirements: report ICD‑10 Z11.51 plus Z01.411 or Z01.419; G0476 is paid only on specified TOBs for hospital claims and is subject to a 5‑year frequency limit (minimum 59 months between screens).

Screening Pap/HPV and pelvic exam coverage criteria

Coverage and billing conditions for screening Pap smears, HPV screening, and screening pelvic examinations.

Screening Pap smear and screening pelvic exam frequency: Medicare pays once every (2, 3) years for low‑risk beneficiaries unless high‑risk factors apply; high‑risk beneficiaries may qualify for more frequent screening (e.g., once every 11 months).

HPV screening (G0476) frequency: paid only once in a 5‑year period (at least 59 months must elapse since prior G0476); beneficiary age must be 30‑65 and claims must include required ICD‑10 codes or they will be denied.

Screening pelvic exam claim requirements: one of the listed low‑risk or high‑risk diagnosis codes must be on the claim and the pelvic exam service must point to that diagnosis code; CWF will reject records missing these pointers.

Pelvic exam intervals

If not high‑risk, screening pelvic exam payable only after at least 23 months have passed since last covered screening pelvic exam (post July 1, 2001 rules).

Coverage and billing criteria for pelvic and prostate services

Summary of coverage and billing rules for screening pelvic and prostate services to guide claims submission and adjudication.

Payment method: pelvic examinations are generally paid under the MPFS except hospital outpatient services under OPPS; RHC/FQHCs and CAHs have special billing/payment rules described in the chapter.

Billing to A/B MAC (B): use G0101 for cervical/vaginal cancer screening (pelvic and clinical breast exam); same‑date E/M may be reported with modifier -25 when separately identifiable and documented.

Prostate screening: screening PSA (G0103) is paid under the CLFS; screening DRE (G0102) paid under MPFS except specified TOBs; use screening diagnosis Z12.5 when applicable; CWF edits enforce age, frequency, sex, and valid HCPCS.

CWF edits will enforce frequency and age limits for prostate screening (once every 12 months for men age ≥50; counting begins the month after the prior test), and appropriate MSN/RA messaging and CARC/RARC codes are used for denials.

Colorectal and prostate screening coverage criteria

Key coverage and billing criteria extracted from this section:

No deductible and no coinsurance for specified screening colorectal tests (FOBTs G0107/82270/G0328, flexible sigmoidoscopy G0104, screening colonoscopies G0105/G0121) and certain stool/blood‑based tests (G0464/81528, G0327) as stated in the chapter.

When a screening colonoscopy becomes diagnostic and the PT modifier is appended, deductible is waived and coinsurance is reduced per CAA schedule (15% for 2023–2026, 10% for 2027–2029, waived from 2030 onward); moderate sedation coinsurance waived when reported with -33.

Age and frequency: flexible sigmoidoscopy minimum age reduced to 45 effective Jan 1, 2023; sigmoidoscopy frequency generally once every 48 months with special 119/10‑year rules if prior screening colonoscopy; G0105 high‑risk colonoscopy payable once every 24 months (>=23 months since prior G0105).

Frequency exception: screening colonoscopy frequency limits do not apply when the colonoscopy follows a positive non‑invasive stool test if the claim includes the KX modifier.

Colorectal screening coverage criteria

Coverage conditions and frequency limits for screening modalities:

Multitarget sDNA (Cologuard / CPT 81528) covered once every 3 years for asymptomatic, average‑risk beneficiaries who meet age criteria (minimum age reduced to 45 effective Jan 1, 2023); report Z12.11 or Z12.12 as appropriate.

Blood‑based biomarker tests (G0327) covered once every 3 years when performed in a CLIA‑certified lab, ordered by a treating physician, beneficiary asymptomatic and average risk, test has FDA market authorization and meets minimal sensitivity (≥74%) and specificity (≥90%), and minimum age reduced to 45 effective Jan 1, 2023.

FOBT (CPT 82270 or G0328) covered once every 12 months (at least 11 months must elapse since prior covered test); written order required from attending clinician (expanded to PA/NP/CNS effective Jan 27, 2014); only one FOBT paid per year.

Screening colonoscopy for average‑risk beneficiaries (G0121) covered once every 10 years (at least 119 months since last covered G0121); frequency adjustments apply when prior sigmoidoscopy or other conditions per policy.

Codes, Rates, and Frequency Limits

Provider Enrollment, Billing, and Documentation Requirements

Note

State vaccination administration rules

State vaccination administration rules: Medicare does not require that influenza, pneumococcal, hepatitis B, or COVID-19 vaccines be administered under a physician's order or supervision. Providers following state or local public health clinic (PHC) rules and licensing must ensure compliance with applicable state licensure when administering vaccines in mass settings.

Medicare allows administration without physician order/supervision for influenza, pneumococcal, hepatitis B, and COVID-19 vaccines.

Billing Rule

Provider enrollment and assignment requirement

Provider enrollment and assignment requirement: Entities and properly licensed individuals that wish to bill for mass immunization roster claims must enroll as provider type 'Mass Immunization Roster Biller' by completing Form CMS-855. Providers enrolling as this type may bill only for influenza, pneumococcal, hepatitis B, and/or COVID-19 vaccines and their administration and must accept assignment for these claims.

Definitions and Key Terms

Waiver of cost-sharing for preventive services

Waiver summaryACA and related statutes waive beneficiary coinsurance/copayment and deductible for IPPE, AWV, and USPSTF A/B preventive services (effective dates described in chapter)

ScopeWaiver applies only to preventive services meeting statutory criteria (not all USPSTF‑recommended services qualify) — consult preventive services table for specifics

Effective datesWaiver of deductible effective Jan 1, 2011 for many services; IPPE deductible waived earlier per MIPPA (Jan 1, 2009) — see chapter for exact effective dates

Payment indicator '1' = 100% payment; '0' = 80% payment

Payment indicator meaningsPayment indicator '1' = 100% payment; payment indicator '0' = 80% payment

Deductible indicator link

Important Code Groups and Modifiers

Relevant HCPCS/CPT/ICD codes for mass immunization billing (quick reference)mixedCovered

G0008, G0009, G0010	Vaccine administration HCPCS codes used for influenza, pneumococcal, hepatitis B (roster/centralized billing)
90630, 90653-90662, 90672-90674, 90682, 90685-90688, 90694, 90756	Influenza virus vaccine procedure codes
90670, 90671, 90677, 90732	Pneumococcal vaccine procedure codes
0636	Revenue code — Pharmacy, drugs requiring detailed coding
0771	Revenue code — Preventive Care Services, Vaccine Administration

Vaccination and mammography billing codes used in edits/coverage (quick reference)mixed

G0008, G0009	Vaccine administration codes (subject to CWF duplicate-payment edits)
90630, 90653-90662, 90672-90674, 90682, 90685-90688, 90694, 90756	Influenza vaccine HCPCS/procedure codes (subject to CWF edits)
90670, 90671, 90677, 90732	Pneumococcal vaccine HCPCS/procedure codes (subject to CWF edits)
77065, 77066, 77067	Key mammography CPT/HCPCS codes used for screening and diagnostic claims
Z12.31	ICD-10-CM code for encounter for screening mammogram (required on screening claims)

Modifiers for interrupted procedures (quick reference)Modifier

-53	Procedure discontinued — professional reporting for interrupted colonoscopy
-73	Procedure discontinued — facility/ASC interrupted reporting
-74	Procedure discontinued after anesthesia — facility/ASC as appropriate

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyChapter 18 — Preventive and Screening Services (Medicare): Coverage, Billing, and Payment

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnroll as a Mass Immunization Roster Biller via CMS-855 and, if centralized billing is used, register with the designated Part B MAC and accept assignment.

SourceLink

On This Page

Providers must retain roster bills with beneficiary signatures according to Medicare record retention rules.

Annual verification: centralized billers must annually contact the designated Part B MAC, provide estimates and clinic/state lists, staffing information, and other data as part of continued participation.

Exceptions

Inpatient hospital roster billing may waive the minimum roster size requirement (fewer than five), provided inpatient status is noted.

When CWF returns a reject for these edits, MACs must deny the second claim and use the appropriate MSN/RA messages per contractor guidance.

Payment method: screening Pap smears and related lab services may be paid under the CLFS or MPFS depending on the code billed; Part B deductible for screening Pap smear services paid under MPFS is waived, while coinsurance may apply for some services; lab‑fee schedule payments have no Part B deductible or coinsurance.

High‑risk beneficiaries: screening pelvic exams may be paid more frequently (minimum 11 months between covered exams when criteria met and high‑risk diagnosis reported).

Payment methods vary by setting: pelvic exams generally paid under MPFS except hospital outpatient under OPPS; RHC/FQHC professional component under all‑inclusive rate; CAH under reasonable cost; SNFs bill A/B MAC (A).

Interrupted colonoscopy: when colonoscopy cannot be completed due to extenuating circumstances, report professional modifier -53 and facility modifiers -73/-74 as appropriate; payment methodologies for interrupted procedures differ by MAC (A) and (B) rules but payment is allowed when coverage conditions met.

CWF edits: Common Working File enforces age, frequency, sex, and valid HCPCS code edits for colorectal screening claims.

Denials and remittance messaging: use specified MSN and ASC X12 835 CARC/remark codes for prostate and colorectal screening denials due to age or timing; RARC N386 indicates decisions based on NCD when applicable.

Screening barium enema (G0106/G0120) may be paid as an alternative to sigmoidoscopy or colonoscopy with frequency rules mirroring the corresponding alternatives and minimum age reduced to 45 effective Jan 1, 2023.

Interrupted colonoscopy reporting: use -53 for professional interrupted colonoscopy and -73/-74 for facility interrupted reporting; maintain documentation to support interruption and payment rules.

CWF will edit colorectal screening claims for age, frequency standards, and valid procedure codes; contractors must apply these edits during adjudication.

Coinsurance rules: a 25% coinsurance applies for colorectal screening colonoscopies and sigmoidoscopies performed in ASCs and non‑OPPS hospitals (historical implementation) with additional exceptions and waivers described in the chapter.

Complete Provider/Supplier Enrollment Application (Form CMS-855) to enroll as 'Mass Immunization Roster Biller'.
Enrolled roster billers may bill only for the specified vaccines and their administration.
Claims submitted by this provider type are reimbursed at the assigned payment rate and require acceptance of assignment.

Denial Risk

Prohibition on beneficiary charges for roster claims

Prohibition on beneficiary charges for roster claims: Entities submitting roster claims must accept assignment and may not collect any payment, donation, coupon, or cost sharing from Medicare beneficiaries for pneumococcal, influenza, hepatitis B, or COVID-19 vaccinations. Upfront payment by the beneficiary with later reimbursement by Medicare is not permitted; providers are required to file claims on behalf of beneficiaries.

No beneficiary charges, donations, coupons, or other cost sharing allowed for roster-billed vaccines.
Entities may bill Medicare for the non-subsidized portion of vaccine costs but may not require beneficiary payment.
Providers must file claims on behalf of beneficiaries per Social Security Act §1848(g)(4)(A).

Billing Rule

Mandatory assignment and beneficiary billing prohibition

Mandatory assignment and beneficiary billing prohibition for centralized billers: Centralized billers must be properly licensed in the state where immunizations are given, operate in at least three payment localities (three different MACs), obtain a provider number from the designated Part B MAC (in addition to any existing Medicare number), and agree to accept assignment. Centralized billers may not collect payment from beneficiaries and must provide beneficiaries a written notice (brochure/handout) identifying the processing Part B MAC at the time of vaccination.

Operate in ≥3 payment localities to qualify as a centralized biller.
Obtain a provider number from the designated Part B MAC via Form CMS-855 for centralized billing purposes.
Must accept assignment; beneficiaries cannot be charged; provide written notice listing the processing Part B MAC to each beneficiary.

Note

Electronic roster claims and EMC guidance

Electronic roster claims and EMC guidance: Centralized billers must submit roster claims in an approved electronic format; paper claims will not be accepted for centralized billing. Where available, MACs must offer free or at-cost electronic billing software and EMC submitters should only submit line items with zero charge if their system accepts 0.00; otherwise omit the line. EMC billers should follow MAC guidance to ensure claims can be processed.

Centralized billers: electronic roster claims only — paper claims not accepted.
MACs should provide free/at-cost electronic billing software for roster claims.
For free immunizations, submit line charges of 0.00 only if the EMC/system accepts zero-dollar line items; otherwise omit the line item per MAC guidance.

Documentation Required

Handling of CWF duplicate-claim rejects

Handling of CWF duplicate-claim rejects: The Common Working File (CWF) will return specific reject codes for duplicate roster or centralized billing claims. MACs must deny the second (duplicate) claim and apply duplicate-claim denial messaging (MSN) and remittance advice codes as specified.

CWF returns reject code '7262' for duplicate edits on Part A claims; MACs must deny the second claim.
For centralized billing/CWF duplicates, MACs must deny the second claim and generate MSN 7.2 ('This is a duplicate of a claim processed by another contractor...') and apply Claim Adjustment Reason Code 18 (Exact duplicate claim / service).

Documentation Required

Payment determination checks for nondigital screening mammography

Payment determination checks for nondigital screening mammography: A/B MACs use the MQSA file to verify facility certification and will check for revenue code 0403, appropriate HCPCS/CPT screening mammography codes, high-risk diagnosis indicators where appropriate, date of last screening, and beneficiary age. Claims lacking proper certification or with mismatched digital/film indicators will be denied.

Verify facility certification via MQSA file; missing or non-matching certification leads to denial or unprocessable return.
For nondigital (film) screening mammography, check revenue code 0403 and corresponding HCPCS/CPT codes (77067/G0206 as applicable by date).
Claims with digital codes must match a facility certified for digital mammography; film-only certifications paired with digital codes will be denied.

Billing Rule

Claim submission validation and denial rules

Claim submission validation and denial rules: Roster cover documents must use a modified Form CMS-1500 with specific populated items (Medicare block, 'SEE ATTACHED ROSTER' patient name, POS 60, vaccine and administration codes, accept assignment X, $0.00 amount paid, signature). Separate Form CMS-1500 must be used per facility/location. For mammography and other services, MACs will return unprocessable or denied claims when required fields (e.g., facility certification number, correct diagnosis codes, or appropriate indicators) are missing or invalid.

Modified Form CMS-1500 cover document requirements: Item 1 Medicare block = X; Item 2 patient name = 'SEE ATTACHED ROSTER'; Item 11 = 'NONE'; Item 24B POS lines = '60'; Item 24D line1 = vaccine code; line2 = administration code; Item 27 accept assignment = YES; Item 29 amount paid = $0.00; Item 31 signature required.
Use a separate Form CMS-1500 for each different facility/physical location to ensure correct payment locality.
Claims missing required facility certification numbers (e.g., mammography) are returned as unprocessable or denied per MAC rules.

Billing Rule

Same-day screening-to-diagnostic billing

Same-day screening-to-diagnostic billing: When a radiologist's interpretation of a screening mammogram results in additional diagnostic films while the beneficiary remains at the facility, both screening and diagnostic mammograms may be billed and will be paid. Providers must append modifier -GG to the diagnostic mammogram to indicate same-patient same-day screening-to-diagnostic services for tracking/data collection; A/B MACs accept GH and GG where appropriate.

Radiologist-ordered additional diagnostic films same day are payable along with the screening mammogram.
Append modifier -GG to the diagnostic mammogram on A/B MAC (B) claims; A/B MAC (A) requires diagnostic revenue code (0401) with appropriate HCPCS/CPT and modifier -GG for same-day diagnostic following screening.
Both A/B MAC (A) and (B) systems must accept GH and GG modifiers where appropriate.

Documentation Required

Mammography remittance advice codes

Mammography remittance advice codes: Use specified CARC/RARC combinations for common mammography denials — age, frequency, and certification issues. Examples include CARC 6 / RARC M37 for under-age denials, CARC 119 / RARC M89 or M90 for frequency-based denials, CARC B7 / RARC N570 for non-certified provider, and CARC 16 / RARC MA128 for missing or invalid facility certification number. Ensure adherence to CAQH CORE messaging standards.

Under-age or age-based denials: CARC 6 / RARC M37 (Group Code CO).
Frequency denials (previous exam within restricted interval): CARC 119 with RARC M89 or M90 as applicable (Group Code CO).
Provider not certified: CARC B7 / RARC N570 (Group Code CO).
Missing/invalid facility certification number: CARC 16 / RARC MA128 (Group Code CO).

Documentation Required

Advance Notice and Same-day E/M rules

Advance Notice and Same-day E/M rules: For services like screening Pap smears that are expected to be noncovered, providers should obtain an Advance Beneficiary Notice (ABN) and report GA modifier. A covered E/M visit may be billed the same day as certain screening procedures (e.g., Q0091 or G0101) if the E/M is a separately identifiable service; report modifier -25 with E/M and document clearly.

Obtain an ABN and report GA when a screening service is expected to be noncovered and the beneficiary will be liable.
When billing a covered E/M and a screening procedure on the same date, report modifier -25 on the E/M and ensure medical record documents the separate service.

Denial Risk

Remittance and denial messaging for prostate screening and colorectal screening denials

Remittance and denial messaging for prostate and colorectal screening denials: Use specified MSN and remittance codes when denying prostate screening (PSA/DRE) for age or time-period reasons. For prostate screening under age 50 use MSN 18.13 (A/B MAC A) or MSN 18.19 (A/B MAC B). For frequency denials use MSN 18.14. On the RA/835, use Claim Adjustment Reason Codes and RARCs: under-age denials — CARC 6 with RARC M82; frequency denials — CARC 119; missing diagnosis Z12.5 — CARC 167 and RARC N386 referencing the NCD.

Prostate screening under age 50: Use MSN 18.13 (A) or MSN 18.19 (B).
Prostate screening frequency denial: Use MSN 18.14 (insert appropriate months).
RA/835 codes: Under-age — CARC 6 + RARC M82; Frequency exceeded — CARC 119; Missing Z12.5 — CARC 167 and RARC N386 referencing the NCD.

Documentation Required

Interrupted colonoscopy documentation and modifiers

Interrupted colonoscopy documentation and modifiers: When a colonoscopy cannot be completed due to extenuating circumstances, providers may bill for an interrupted colonoscopy. Facility and professional claims must use the appropriate modifiers: professional providers use modifier -53 for interrupted procedures (or -53 for CAHs electing Method II per guidance), ASCs/facility use -73 or -74 as appropriate. Maintain adequate medical record documentation explaining the incomplete procedure.

Professional claims for interrupted colonoscopy: suffix colonoscopy code with modifier -53 (A/B MACs (B) payment methodology may use one-half the value).
Facility/ASC claims: suffix colonoscopy code with modifier -73 or -74 as appropriate; CAHs electing Method II may use modifier -53 for professional services and revenue code 075X for technical/facility component.
Retain detailed medical record documentation to support the interrupted procedure in case requested by the MAC.

Payment indicators are tied to deductible indicators in CWF records for vaccine products/services

Use in claims processingMAC (Part B) records must set payment indicator per vaccine type to reflect 100% payment for listed vaccines

Deductible indicator '1' = zero deductible; '0' = deductible applies

Deductible indicator meaningsDeductible indicator '1' = zero deductible; deductible indicator '0' = deductible applies

Vaccine examplesPneumococcal, influenza, hepatitis B, and COVID‑19 vaccines have deductible indicator = '1' per MAC (Part B) records

Interaction with payment indicatorDeductible indicator works in conjunction with payment indicator and type‑of‑service fields in CWF for correct adjudication

POS codes for mass immunization and PHCs

POS for PHCs and mass immunizationPOS 71 — State or Local Public Health Clinic for PHCs; POS 60 — Mass Immunization Center to be used on preprinted CMS‑1500 for roster claims regardless of actual site

POS 99Use POS 99 (Other Unlisted Facility) when no other POS code applies

Normal POS usageUse normal POS codes in non‑roster/mass immunization situations

Mass Immunization Roster Biller

DefinitionMass Immunization Roster Biller — provider enrollment type for entities that provide mass immunizations and may not otherwise qualify as Medicare providers; may bill only for pneumococcal, influenza, hepatitis B, and COVID‑19 vaccines and their administration

Enrollment requirementMust enroll using CMS‑855 provider/supplier enrollment application

Billing limitationEntities enrolled as this type may not bill Medicare for services other than the listed vaccines and their administration

Centralized biller

DefinitionCentralized biller — an approved provider that submits all influenza, pneumococcal, and COVID‑19 vaccination claims to a single designated MAC (specialty contractor) regardless of service locality

QualificationTo qualify, provider must operate in at least three payment localities (three different MACs) and enroll per CMS instructions; centralized billers must roster bill, accept assignment, and bill electronically

Assigned contractorCMS selects the contractor (currently Novitas for centralized billing) to process centralized billing claims

Mass immunizer

DefinitionMass immunizer — any entity that gives influenza, pneumococcal, or COVID‑19 vaccinations to a group of beneficiaries (e.g., public health clinics, shopping malls, senior homes, health fairs)

Roster billing applicabilityMass immunizers may use simplified roster billing procedures for eligible vaccinations when meeting roster minimums and data requirements

Electronic roster claimsMACs (Part A) encourage EMC; electronic roster claims paid faster than paper roster bills (paper roster bills treated as payment floor items)

Centralized billing

DefinitionCentralized billing — process allowing a provider delivering mass immunization services to send all claims to a single contractor for payment regardless of geographic locality (limited to influenza, pneumococcal, COVID‑19)

Billing constraintsCentralized billers must roster bill, accept assignment, and submit claims electronically; vaccines reimbursed per standard drug/biologics method and administration per locality‑adjusted MPFS

Enrollment/contactProviders interested in centralized billing must contact designated contractor (Novitas) to begin enrollment

Electronic roster claims

DefinitionElectronic Roster Claims (EMC) — roster billing submitted in approved electronic formats; EMCs generally paid faster than paper roster bills

MAC obligationsMACs (Part A) must offer free or at‑cost electronic billing software if available and ensure user‑friendly roster billing software

Paper roster noteFor payment floor purposes roster bills are paper bills and may be paid slower than EMC; centralized billers must submit electronically per program rules

MQSA / FDA certification

MQSA/FDA certification requirementMQSA (FDA) certification is required for facilities to bill Medicare for mammography services — A/B MACs use weekly MQSA file to verify certification and effective/expiration dates

6‑digit facility numberClaims must include the facility's FDA‑assigned 6‑digit mammography certification number; claims lacking it are returned unprocessable or denied if mismatched

Film/digital indicatorsMQSA file indicates film (record type=1) or digital (record type=2) certification; claims must include matching film/digital indicator or face denial

Independent Diagnostic Testing Facility (IDTF)

IDTF requirementIndependent Diagnostic Testing Facility (IDTF) — an entity furnishing mammography services must have FDA certification to perform such services; screening mammography payable when performed by a certified IDTF

Enrollment guidanceEntities performing only diagnostic mammography should not enroll as IDTFs; follow Chapter 35 IDTF claims processing rules

Payment noteIDTFs are paid for screening mammography when certified per MQSA and Medicare rules

CAH optional method

CAH optional methodCritical Access Hospital (CAH) optional (all‑inclusive) method: CAHs may elect cost‑based outpatient reimbursement with professional component paid at 115% of the allowed amount under specified conditions

Billing specificsCAHs electing optional method bill A/B MAC (A) with TOB 85X, revenue code 0403 and HCPCS 77067 (TC) and include professional component separately with appropriate revenue codes

Effect on percentagesOptional method can alter effective beneficiary payment percentages (e.g., 115% of allowed amount interactions noted in payment tables)

6-digit FDA certification number

6‑digit FDA certification numberThe facility's FDA‑assigned 6‑digit mammography certification number must be included on mammography claims (item 32 on CMS‑1500); missing or invalid numbers cause unprocessable/denied claims

Match to MQSA fileA/B MACs match the submitted 6‑digit number to the weekly MQSA file; mismatches result in denial

Retention in provider filesA/B MACs retain the certification number in their provider files for processing and validation

-GG

Modifier purposeModifier -GG — append to diagnostic mammography when screening converts to diagnostic on the same day for tracking and data collection; Medicare reimburses both screening and diagnostic when -GG used

Billing instructionFor A/B MAC (B) claims include -GG on diagnostic mammography; A/B MAC (A) require diagnostic revenue code and -GG where applicable

Reimbursement effectBoth screening and diagnostic mammography reimbursable when -GG appended to diagnostic code on same‑day conversion

High risk factors (cervical cancer)

High‑risk factors (cervical cancer)Examples include: early onset sexual activity (under 16), multiple sexual partners (5+ lifetime), history of STD (including HIV), fewer than three negative Pap smears within previous 7 years, DES‑exposed daughters

Use of codesHigh‑risk clinical or historical factors should be reported with appropriate ICD‑10‑CM high‑risk codes (see chapter lists) to support more frequent screening

Impact on frequencyPresence of high‑risk factors permits more frequent screening (e.g., pelvic/Pap once every 11 months) when documented

COUNTING

Counting conventionCOUNTING: Start counts to determine intervals beginning with the month after the month in which the previous test/procedure was performed

ExamplesTo compute eligibility intervals (e.g., 11, 23, 35 months), begin counting the month after the prior service month per provided examples

Applies toUsed for Pap, pelvic, mammography, and other screening interval determinations referenced in the chapter

Payment method

Payment method summaryPayment methods referenced include MPFS, CLFS, OPPS, and reasonable cost (for CAHs/hospitals) — determination is code and setting dependent

Coinsurance/deductible variationsDeductible and coinsurance application vary by screening vs diagnostic classification and by payment method (e.g., screening mammography TC often deductible waived; diagnostic may have deductible)

ExamplesFOBT and certain stool/blood tests paid under CLFS; mammography technical component may be paid as lower of charge or MPFS TC depending on setting

RHC/FQHC billing

RHC/FQHC billing ruleThe professional component of screening Pap smear furnished within an RHC/FQHC is considered an RHC/FQHC service and billed to A/B MAC (A) under bill type 71X/73X with revenue code 052X

Technical componentThe technical component of screening Pap smear is outside the RHC/FQHC benefit and billed separately (A/B MAC B) when furnished by an independent RHC/FQHC provider

Provider‑based TC billingIf TC furnished within a provider‑based RHC/FQHC, the provider of that service bills A/B MAC (A) under TOB 13X/14X/22X/23X/85X using base provider number

Screening pelvic examination

Screening pelvic exam elementsScreening pelvic examination should include at least 7 of 11 specified elements (e.g., breast inspection/palpation, digital rectal exam, external genitalia, urethra, bladder, vagina, cervix, uterus, adnexa, anus/perineum)

Who may performPerformed by physician, certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist authorized under State law

Ordering requirementExamination does not have to be ordered by a physician or other authorized practitioner

High risk for cervical/vaginal cancer

High‑risk definitionHigh risk for cervical/vaginal cancer includes early sexual activity, multiple partners, history of STD/HIV, fewer than three negative Paps in prior seven years, DES exposure, and other specified personal risk factors

Coding to indicate riskUse ICD‑10‑CM codes listed in the chapter (high‑risk diagnosis code lists) to support more frequent screening and payment

Effect on payment frequencyWhen high‑risk diagnosis codes are present, screening Pap/pelvic exams may be paid more frequently (e.g., once every 11 months)

Screening digital rectal examination

Screening DRE definitionScreening digital rectal examination (G0102) is a clinical exam of prostate for nodules/abnormalities performed by authorized practitioners

Bundling ruleG0102 is bundled into payment for a covered E/M if furnished same day; otherwise payable separately if coverage requirements are met

FrequencyDRE may be paid once every 12 months for men aged ≥50 when CWF/interval rules met

Screening PSA

Screening PSA definitionScreening PSA (G0103) measures prostate specific antigen in blood and must be ordered by authorized practitioners

Frequency and ageScreening PSA payable once every 12 months for men aged ≥50 (count begins the month after prior test)

Payment methodG0103 paid under CLFS or MPFS depending on billing contractor and code as specified in chapter sections

Payment systems

Payment systems referencedPayment contexts include MPFS, CLFS, OPPS, and ASC/CAH reasonable cost methods depending on code and setting

ExamplesFOBTs and stool/blood tests paid under CLFS; colonoscopies and sigmoidoscopies under OPPS for outpatient hospital departments; CAHs may be paid reasonable cost

Differing cost‑sharingDeductible/coinsurance application varies by test and setting per chapter (e.g., some stool/blood tests have no deductible/coinsurance)

PT modifier and coinsurance rules

PT modifier and coinsurance rulesWhen a screening colorectal procedure becomes diagnostic and PT modifier is appended, deductible is waived and coinsurance is reduced per CAA schedule (15% for 2023–2026; 10% for 2027–2029; waived from 2030)

Moderate sedationCoinsurance/deductible waived for moderate sedation (G0500 or 99153) when furnished with screening colonoscopy and reported with modifier -33; if screening becomes diagnostic report -PT and only deductible waived

ApplicabilityPT modifier rules apply when screening becomes diagnostic/therapeutic during the same encounter — follow claim coding and modifier guidance

High risk for developing colorectal cancer

High‑risk colorectal definitionHigh‑risk for developing colorectal cancer: close relative with colorectal cancer or adenomatous polyp, family history of FAP or HNPCC, personal history of adenomatous polyps or colorectal cancer, or inflammatory bowel disease

High‑risk colonoscopy frequencyG0105 (screening colonoscopy for high‑risk individuals) payable once every 24 months (≥23 months since prior G0105)

DocumentationProviders must document high‑risk criteria in medical record to support more frequent screening claims

Blood-based biomarker test (G0327)

G0327 scopeBlood‑based biomarker test (HCPCS G0327) covered once every 3 years when performed in a CLIA‑certified lab, ordered by a treating physician, beneficiary asymptomatic and average risk, and the test has FDA authorization with sensitivity ≥74% and specificity ≥90%

Age and risk criteriaOriginal age criterion 50–85 (reduced to minimum age 45 effective Jan 1, 2023); beneficiary must be asymptomatic and average risk

Coding requirementClaims for G0327 must include appropriate screening diagnosis (Z12.11 or Z12.12) per chapter guidance