Currentpriority healthPolicy N/A

Medicare coverage rules for selected screening tests and durable medical equipment

Federal Medicare Part B coverage conditions and limitations for screening mammography, colorectal cancer screening (fecal occult blood tests, flexible sigmoidoscopy, colonoscopy, barium enema) and durable medical equipment including power mobility devices; affects providers billing Medicare and beneficiaries.

Policy Summary

Payerpriority health

PolicyMedicare coverage rules for selected screening tests and durable medical equipment

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFor power mobility devices, the physician must perform a face-to-face exam and provide a written prescription and documentation to the supplier (prescription received within 45 days).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2-viewminimum exposures required for screening mammography

35mammography minimum age

>=50colorectal screening minimum age

11 monthsinterval mammography/fecal occult

23 monthshigh-risk colonoscopy/barium enema interval

Coverage Criteria for Screening Tests and DME

Age and Interval Thresholds / Coding-related Rules

Age and interval thresholds

Screening mammography minimum agePayment may not be made for screening mammography performed on a woman under age 35 (minimum age 35)

Mammography intervalFor an asymptomatic woman over 39, payment may be made after at least 11 months have passed since the month of the last screening mammography

Colorectal screening minimum agePayment may not be made for screening fecal-occult blood tests, flexible sigmoidoscopy, or barium enema for individuals under age 50 (minimum age 50)

Fecal-occult intervalFor individuals 50+, payment may be made for a screening fecal-occult blood test after at least 11 months have passed since the month of the last test

High-risk colonoscopy/barium enema intervalFor individuals at high risk, payment may be made for screening colonoscopy or barium enema after at least 23 months have passed since the month of the last screening colonoscopy or barium enema

Policy Summary

Payerpriority health

PolicyMedicare coverage rules for selected screening tests and durable medical equipment

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFor power mobility devices, the physician must perform a face-to-face exam and provide a written prescription and documentation to the supplier (prescription received within 45 days).

SourceLink

On This Page

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Provider Requirements and Documentation

Documentation Required

Power mobility device documentation and timing

Power mobility device (PMD) claims require specific documentation and timing. Ensure the treating physician or practitioner performs a documented face-to-face exam, provides a written prescription that meets PMD content requirements, and that the supplier receives the prescription within the required timeframe.

Supplier must receive the written prescription within 45 days after the face-to-face examination.
Prescription must include beneficiary name, date of face-to-face exam, diagnoses/conditions the PMD is expected to modify, description of the item (narrative of specific PMD type), length of need, and physician/treating practitioner signature and date.

Documentation Required

Face-to-face examination and prescription requirements for PMDs

A documented face-to-face examination by the physician or treating practitioner is required to evaluate and determine medical necessity for the PMD as part of the beneficiary's overall treatment plan. The practitioner who performs the exam must be the one completing the prescription.

Treating practitioner may be a physician assistant, nurse practitioner, or clinical nurse specialist who has conducted the face-to-face exam.
Prescription must be completed by the physician or treating practitioner who performed the face-to-face exam and provided to the beneficiary or supplier within 45 days.

Billing Rule

Timing/interval restrictions between colorectal screening modalities

Timing and interval restrictions apply between colorectal screening modalities; verify prior screening dates and modality before billing.

Screening fecal-occult blood tests, flexible sigmoidoscopy, and barium enema are not payable for individuals under age 50.
For individuals ≥50 (not high risk): screening flexible sigmoidoscopy or barium enema — at least 47 months must have passed since the last screening flexible sigmoidoscopy or barium enema before payment.
Screening colonoscopy for individuals not at high risk — generally payable after at least 119 months following the month of the last screening colonoscopy (with specific exceptions).
For individuals at high risk: screening colonoscopy or barium enema — generally payable after at least 23 months since the last screening colonoscopy or barium enema.

Background and Scope

This policy summarizes Medicare Part B limits and conditions on coverage for selected preventive screening services and certain durable medical equipment. Key regulatory constraints include age and interval limits for screening tests (for example, screening mammography has minimum-age and interval rules), modality-specific timing rules for colorectal cancer screening (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, barium enema) that vary by risk status, and documentation/prescription requirements for DME such as power mobility devices (PMDs).

Coverage for DME under Part B requires that equipment be used in the patient’s home, and some institutions (specifically hospitals, CAHs, and SNFs) are not considered homes for this purpose. For PMDs, the treating physician or practitioner must perform a face-to-face examination, write a prescription containing specified elements, and ensure the supplier receives the prescription within 45 days of the exam to support payment.

Key Definitions

Individual at high risk for colorectal cancer

Definition (high risk)An individual at high risk has any of: a close relative (sibling, parent, or child) with 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; or inflammatory bowel disease including Crohn's disease and ulcerative colitis.

Implication for screening colonoscopyScreening colonoscopies are covered in the case of an individual at high risk for colorectal cancer

Examples of screening tests includedScreening tests include fecal-occult blood tests, flexible sigmoidoscopies, screening colonoscopies (for high-risk individuals), and screening barium enemas

Power mobility device (PMD)

DefinitionA power mobility device (PMD) is a covered class of wheelchairs including a power wheelchair (a four-wheeled motorized vehicle with steering operated by an electronic device or joystick) or a power-operated vehicle (a three- or four-wheeled motorized scooter operated by a tiller) that a beneficiary uses in the home.

Device examplesIncludes power wheelchairs and power-operated scooters

Home use requirementPMD is an item of durable medical equipment intended for use in the beneficiary's home

Prescription (for PMD)

Required prescriberPrescription must be completed by the physician or treating practitioner who performed the face-to-face examination

Required content—patient and examMust include the beneficiary's name and the date of the face-to-face examination

Required content—clinical details and itemMust include the diagnoses and conditions the PMD is expected to modify, a description of the item (narrative of specific PMD type), and the length of need

AuthenticationMust include the physician or treating practitioner's signature and the date the prescription was written