CurrentUCarePolicy N/A

Preventive and Screening Services (Chapter 18)

Governance of preventive and screening services coverage, coding, billing, and payment processes (Medicare-focused) across multiple service types; affects providers submitting preventive service claims and billing entities such as RHCs, FQHCs, MACs, hospitals, and mass immunizers.

Policy Summary

PayerUCare

PolicyPreventive and Screening Services (Chapter 18)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionWaiver of cost sharing requires 100% payment for IPPE, AWV, and USPSTF A/B preventive services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+sections

Numerouspreventive services covered

Waiver applieswaiver of cost sharing

Coverage, Billing, and Payment Criteria

Codes, Modifiers, and Billing Values

PrEP codes and supply feesmixedCovered

G0011	PrEP-related preventive service code (per table entry)
G0012	PrEP injection service (per table entry)
J0739	Injection, cabotegravir, 1 mg (PrEP)
J0750	Emtricitabine/tenofovir disoproxil fumarate 200/300 mg (PrEP)
Q0516	Pharmacy supplying fee for oral PrEP per 30-days

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.

Relevant procedure and ICD-10 diagnosis codes for screening Pap and HPVmixedCovered

Q0091	Screening Pap smear (screening cytology)
G0476	Cervical cancer screening, all-inclusive HPV co-test with cytology
Z01.411	Encounter for gynecological examination (routine) with abnormal findings
Z01.419	Encounter for gynecological examination (routine) without abnormal findings
Z11.51	Encounter for screening for HPV
Z12.4	Encounter for screening for malignant neoplasm of cervix
Z77.29	Contact with and (suspected) exposure to other hazardous substances (used as high-risk indicator)

Key colorectal screening codes and replacementsCPT | HCPCS | mixedCovered

82270	FOBT; fecal-occult blood tests, 1-3 determinations
G0104	Screening flexible sigmoidoscopy
G0105	Screening colonoscopy; high risk
G0121	Screening colonoscopy; not high risk
G0328	Immunoassay FOBT
G0464 / 81528	Multitarget sDNA colorectal cancer screening (Cologuard) — G0464 replaced by CPT 81528
G0327	Blood-based biomarker colorectal cancer screening

Charge substitute when vaccine provided free — $0.01 billing guidance

Billing substitute when component freeIf vaccine product is supplied at no charge (e.g., during a public health emergency), submit a $0.01 charge for the component not provided so the claim can process; contractors will deny vaccine reimbursement when vaccine was provided at no charge.

When only administration billedIf only administration is billed because the vaccine was free, submit the administration HCPCS (e.g., G0008 for influenza) and a $0.01 charge for the vaccine if the billing system requires both fields.

Separate-entity furnishingWhen vaccine and administration are furnished by different entities, they should submit separate claims (vaccine supplier bills vaccine HCPCS; administrator bills administration HCPCS).

COVID-19 admin temporary rate — national payment rate during PHE

Temporary COVID-19 administration national rateBeginning January 1, 2022 and through the end of the calendar year in which the PHE ends, the national payment rate for COVID-19 vaccine administration is $40 (adjusted by MPFS geographic indices).

Post-PHE alignmentEffective January 1 of the year following the year in which the PHE ends, the COVID-19 administration rate will be aligned with the administration rate for other Part B preventive vaccines.

Assignment and limiting chargeAssignment for administration is not mandatory except for roster/centralized billers; MACs may not apply the limiting charge provision for these vaccines and administration.

roster billing minimums — roster billing minimum beneficiary count and inpatient exception

Roster billing minimum beneficiariesRoster billing requires immunizations of at least five beneficiaries on the same date to qualify for simplified roster claims (exception below).

Inpatient hospital exceptionFor hospital inpatient roster billing the five-beneficiary requirement is waived; rosters may contain fewer than five inpatients and must indicate inpatient status.

Eligible vaccines for roster billingRoster billing is available only for influenza, pneumococcal, and COVID-19 vaccinations (not available for hepatitis B).

CAH optional method effective date window — timing guidance for optional CAH method

Optional CAH method availability windowThe CAH optional (All-Inclusive) method is available for cost reporting periods beginning on or after October 1, 2001; the optional method applies to dates of service on/after July 1, 2001 as noted in the payment table.

Billing under optional methodCAHs electing the optional method bill TOB 85X with revenue code 0403 and HCPCS 77067 for the technical component and report the professional component separately (rev codes 96X/97X/98X).

Standard method contrastUnder the standard method CAHs bill the technical component on TOB 85X, rev code 0403, HCPCS 77067 and professional services billed to A/B MAC (B) paid under MPFS.

CWF type of service values (post-1998) — screening vs diagnostic TOS values

CWF Type of Service values (post‑1998)For services on/after January 1, 1998 the CWF Type of Service field must be '1' for medical care (screening) or '4' for diagnostic radiology (diagnostic).

Use with POS and deductible indicatorAlso fill in Place of Service and set deductible indicator to '1' for screening mammography (not subject to deductible) when submitting to CWF.

CWF age/frequency editsCWF uses Type of Service in conjunction with other fields to apply age and frequency edits for screening services; diagnostic has no frequency limit.

G0476 frequency — screening HPV co-test frequency constraint

G0476 billing TOB restrictionHCPCS G0476 (HPV co-test all‑inclusive with cytology) shall be paid only on TOBs 12X, 13X, 14X, 22X, 23X, and 85X per TOB guidance.

Frequency constraintG0476 is an all‑inclusive HPV co‑test and is subject to age and other clinical criteria; frequency edits and appropriate diagnoses must be present to avoid denial (see HPV screening rules).

Diagnosis and claim formWhen billing G0476 use the specified TOBs and revenue/code guidance on Form CMS‑1450; ensure required diagnosis codes are included per HPV screening rules.

Q0091 frequency for low-risk — frequency for low-risk Pap screening

Q0091 low‑risk screening frequencyMedicare pays for HCPCS Q0091 (screening Pap smear) every 2 years for low‑risk beneficiaries (CWF edits enforce the 2‑year interval).

Low‑risk diagnosis examplesRecognized low‑risk ICD‑10 codes include Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z12.89 which support the biennial interval.

Claim annotations for repeatsIf a repeat specimen is collected due to unsatisfactory result, bill Q0091 with modifier -76 (repeat procedure by same physician).

Q0091 frequency for high-risk — annual frequency for high-risk Pap screening

Q0091 high‑risk screening frequencyMedicare pays for HCPCS Q0091 annually for high‑risk beneficiaries (CWF edits enforce an every‑year interval for high‑risk codes).

High‑risk diagnosis examplesRecognized high‑risk ICD‑10 codes include Z77.29, Z72.51, Z72.52, Z72.53, Z77.9, Z91.89 and specific personal history codes listed in guidance.

Modifiers and ABNIf provider anticipates denial due to prior covered Q0091 within the edit window, obtain an ABN and report GA modifier; report modifier 25 for separately identifiable E/M services on same date.

FOBT frequency — annual fecal occult blood test frequency

FOBT annual frequencyMedicare will pay for a screening FOBT (CPT 82270 or HCPCS G0328) once every 12 months (at least 11 months must have passed since the last covered FOBT).

Minimum age updateEffective January 1, 2023 the minimum age for FOBT screening was reduced to 45 years and older (applies to CPT 82270/G0328).

Ordering requirementFOBT screening requires a written order from the beneficiary's attending physician (or PA/NP/CNS for dates of service on/after January 27, 2014).

Screening colonoscopy (not high risk) frequency — once every 10 years guidance

Screening colonoscopy (average‑risk) frequencyHCPCS G0121 screening colonoscopy for individuals not meeting high‑risk criteria is payable once every 10 years (at least 119 months since prior covered G0121).

Interaction with prior sigmoidoscopyIf beneficiary previously had a covered screening flexible sigmoidoscopy (G0104), a G0121 colonoscopy is payable only after at least 47 months have passed since the last covered G0104.

Conversion to diagnosticIf during the screening colonoscopy a lesion is removed or biopsy performed, bill the appropriate diagnostic colonoscopy code with modifier -PT rather than G0121.

Screening colonoscopy (high risk) frequency — once every 24 months guidance

Screening colonoscopy (high‑risk) frequencyHCPCS G0105 screening colonoscopy for beneficiaries at high risk may be paid once every 24 months (at least 23 months since the last covered G0105).

High‑risk determinationRefer to program criteria (§60.3) to determine high‑risk status; if lesion removal/biopsy occurs bill diagnostic colonoscopy with -PT modifier as appropriate.

When diagnostic procedure appliesIf a biopsy or removal converts the service, bill the diagnostic colonoscopy/procedure with modifier -PT rather than G0105 for correct payment.

Multitarget sDNA and blood-based biomarker frequency — once every 3 years

Multitarget sDNA & blood‑based biomarker frequencyCologuard (G0464 / CPT 81528) and blood‑based biomarker tests (G0327) are covered once every 3 years when beneficiary meets criteria (age, risk, CLIA lab for blood test).

Cologuard eligibility criteriaMultitarget sDNA (G0464/81528) coverage requires ages 50–85 (minimum age reduced to 45 effective Jan 1, 2023), asymptomatic status, and average risk per criteria; report Z12.11 or Z12.12 diagnosis.

Blood‑based test requirementsG0327 (blood‑based biomarker) is covered once every 3 years when performed in a CLIA‑certified lab, ordered by treating physician, and all other requirements are met (effective Jan 19, 2021).

Provider Responsibilities, Enrollment, and Billing Procedures

Note

Waiver of Cost Sharing for Preventive Services

IPPE, AWV, and USPSTF A/B preventive services are paid at 100% — no beneficiary coinsurance, copayment, or deductible when Medicare covers the service and it is appropriate for the individual.

Medicare statutory waiver of cost sharing applies to IPPE, AWV, and USPSTF A/B recommended preventive services.

Billing Rule

Billing and Primary Payer Responsibilities for Vaccine Claims

When the only services on the claim are pneumococcal, influenza, or COVID-19 vaccines (or their administration), MSP utilization edits in CWF are bypassed. If the beneficiary's group health plan covers vaccines, the primary payer must be billed. First-claim development alerts are not generated when only these vaccines/administrations are billed. If other services are billed on the same claim, usual MSP development applies; bill the primary payer when applicable.

CWF/MSP edits bypassed only when vaccines and/or administration are the sole services on the claim.
If provider knows a group health plan covers the vaccine, bill the primary payer per MSP rules.

Prior Authorization

Mass Immunizer Enrollment and Assignment

Mass immunizers must enroll using Form CMS-855 as provider type 'Mass Immunization Roster Biller.' Enrollment limits billing to pneumococcal, influenza, and/or COVID-19 vaccines and their administration. Claims from this provider type are reimbursed at the assigned payment rate.

Mass Immunization Roster Billers may only bill for pneumococcal, influenza, and COVID-19 vaccines and administration.
Claims reimbursed at the assigned rate; enrollment via CMS‑855 required.

Documentation Required

Ordering Requirements and Claim Elements for Vaccines

Medicare requires a physician order and referring/ordering information for certain vaccines: hepatitis B vaccine must be administered under physician order and the referring physician's NPI must be reported on vaccination claims. If a doctor of medicine/osteopathy did not order influenza vaccine in certain settings, MAC (Part A) claims require the provider's own NPI in the attending physician field. Contractors may correct missing diagnosis or HCPCS on vaccine claims when narrative/diagnosis indicate the vaccine provided.

Hepatitis B vaccine: physician order required; report referring physician NPI on claim.
If influenza vaccine not ordered by MD/DO, report provider's own NPI in attending physician field for MAC (Part A) claims.
Contractors may enter a missing diagnosis or correct an incorrect HCPCS when claim narrative and diagnosis support the vaccine provided.

Billing Rule

Centralized Billing Enrollment and Provider Obligations

Centralized billing allows a single contractor to receive mass immunization claims for influenza and pneumococcal (and ongoing COVID-19 centralized enrollments). To apply, contact the designated MAC/contractor (e.g., Novitas for influenza/pneumococcal). Centralized billers must: provide services in at least three payment localities processed by different contractors; be licensed where immunizations are given; accept assignment (no beneficiary charges); submit roster bills in approved electronic format; collect accurate beneficiary identifiers (name, MBI, DOB, sex, address, signature); provide beneficiaries written notice of the processing Part B MAC; and not collect payment from beneficiaries.

Qualification: mass vaccination in ≥3 payment localities with ≥3 different contractors.
Centralized billers must accept assignment; beneficiaries cannot be charged.
Claims submitted as roster bills electronically; paper not accepted.
Collect and submit correct beneficiary Medicare information (including MBI) and provide a written notice/brochure naming the processing Part B MAC to each beneficiary.

Denial Risk

CWF Duplicate-Vaccine Rejects and MAC Actions (Part A & Part B)

CWF duplicate-vaccine edits: CWF returns reject code '7262' to MAC (Part A) for duplicate vaccine claims — MAC (Part A) must deny the second claim using standard duplicate denial messaging. For MAC (Part B), CWF returns a specific reject for duplicate vaccine line edits and the MAC must deny the second claim; remittance messaging should include MSN 7.2 and CARC 18 when applicable.

MAC (Part A): CWF reject '7262' — deny second/duplicate claim.
MAC (Part B): CWF line‑level edits for specific influenza, pneumococcal, and administration HCPCS codes will reject a second claim with different MAC number but same MBI and DOS; deny second claim and generate MSN 7.2 and CARC 18.
Affected influenza codes include 90630, 90653–90662, 90672–90674, 90682, 90685–90688, 90694, 90756; pneumococcal codes 90670, 90671, 90677, 90732; administration G0008/G0009.

Documentation Required

Facility MQSA Certification Number Required on Mammography Claims

Include the facility's 6‑digit FDA/MQSA mammography certification number on claims (item 32 on CMS‑1500). If the certification number is missing the claim will be returned as unprocessable; if the number does not match MQSA file it will be denied. A/B MACs use the MQSA file to verify certification and the number is retained in MAC provider files.

Report the FDA‑assigned 6‑digit certification number on claims (item 32 CMS‑1500).
Missing certification number = return as unprocessable for A/B MAC (B); mismatched number = denial.
MACs verify certification against the weekly MQSA file.

Billing Rule

HCPCS, Modifiers, Film/Digital Indicators, and NPI Billing Rules for Mammography

Follow HCPCS and modifier rules to avoid duplicate/professional/facility billing errors: use '-TC' for technical component and '-26' for professional component; for entities billing globally leave modifier position #1 blank; include appropriate film (1) or digital (2) indicators; and submit the performing provider's NPI when required (e.g., anti‑markup or acquired services). Ensure not to bill add‑on codes alone.

Technical component billing: use HCPCS modifier -TC; professional component use -26.
Global billing: ensure modifier position #1 is blank when billing globally.
Include film (1) or digital (2) indicator as required and submit performing provider NPI when services are acquired from another billing jurisdiction.
Do not submit add‑on codes without the appropriate primary mammography code.

Billing Rule

Same‑day Screening-to‑Diagnostic Mammography Billing (Use of -GG Modifier)

When a screening mammogram converts to a diagnostic mammogram on the same day for the same beneficiary, append modifier -GG to the diagnostic mammography and bill both the screening and diagnostic services on the same claim; both are reimbursable. Use -GG for tracking/data collection and report both codes on the same claim.

Append modifier -GG to the diagnostic mammogram when screening converts to diagnostic same‑day.
Bill both screening and diagnostic mammography on the same claim; Medicare reimburses both services.

Documentation Required

ABN Requirement for Anticipated Denial of Q0091 and Use of Modifier 25

For HCPCS Q0091 (screening Pap) claims expected to be denied as not reasonable and necessary (e.g., low‑risk patient already had a covered Q0091 within 2 years), obtain an Advance Beneficiary Notice (ABN) and report modifier GA on the claim. When an E/M is separately identifiable on the same date, report modifier 25 with the E/M and document clearly in the medical record; both line items should be separate on the claim.

Obtain ABN and append GA when billing Q0091 expected to be denied; patient may be billed per ABN rules.
If an E/M is separately identifiable and reported same day as Q0091, report modifier 25 on the E/M and document separate services; list both codes as separate line items.

Billing Rule

Modifiers for Interrupted Colonoscopy (-53, -73, -74)

When a colonoscopy is attempted but not completed due to extenuating circumstances, use the appropriate modifiers to indicate an interrupted procedure: professional providers append modifier -53; ASCs/facility claims use -73 or -74 as appropriate. A/B MAC (A) guidance allows -73/-74 for facility and -53 for physician professional services; A/B MAC (B) pays interrupted colonoscopy using -53 for professional and -73/-74 for facility with payment calculations per MPFS guidance.

Professional/procedure interrupted: suffix with -53.
Facility/ASC interrupted: suffix with -73 or -74 as appropriate.
Maintain documentation supporting the extenuating circumstances; MACs may require records to substantiate the incomplete procedure.

Key Terms and Definitions

USPSTF A/B preventive services definition — full payment, no cost sharing

USPSTF A/B preventive services definitionPreventive services recommended by the USPSTF with a Grade A or B must be paid at 100% by Medicare (coinsurance, copayment and deductible waived) when appropriate for the individual under ACA provisions.

Effective dates for waiversDeductible waiver effective for AWV as of Jan 1, 2011; IPPE deductible waiver effective Jan 1, 2009; refer to Preventive Services Table for specific USPSTF ratings.

LimitationsNot all Medicare preventive services recommended by USPSTF have A/B grades; only those with Grade A or B meet statutory waiver criteria for full payment and waived cost‑sharing.

IPPE / AWV definitions — Initial Preventive Physical Examination and Annual Wellness Visit

IPPE definitionIPPE refers to the Initial Preventive Physical Examination; deductible waiver for IPPE effective January 1, 2009 per statutory amendment.

AWV definitionAWV refers to the Annual Wellness Visit; deductible waiver for AWV effective January 1, 2011 per ACA provisions.

Coverage contextBoth IPPE and AWV are preventive visits subject to waiver of deductible/coinsurance when furnished and appropriate for beneficiary per program rules.

Cost-sharing waiver summary — coinsurance/copayment/deductible waived for specified preventive services per ACA

Cost‑sharing waiver summaryCoinsurance, copayment and deductible are waived for USPSTF Grade A/B preventive services and for specified Medicare preventive visits (IPPE, AWV) as required by the ACA and related statutes.

Scope of waiverWaiver applies only to services that meet statutory criteria (USPSTF A/B and specified preventive services); refer to preventive services table for determinations.

Implementation notesEffective dates vary by service (see IPPE/AWV effective dates); contractors follow statutory guidance when adjudicating claims and applying waivers.

Z23 immunization diagnosis code — use Z23 for preventive vaccine encounters including COVID-19

Z23 immunization diagnosis codeICD‑10‑CM code Z23 (Encounter for immunization) must be reported for preventive vaccine encounters, including COVID‑19 immunizations; all vaccine claims must include appropriate diagnosis and procedure codes.

When sole purpose is vaccineIf the sole purpose of the visit is to receive a vaccine or vaccine is the only service billed, Z23 is the applicable diagnosis to use on the claim.

Claims processing noteClaims missing appropriate diagnosis, procedure, or admin code may not process correctly; contractors may deny or return unprocessable claims.

Roster billing definition — simplified mass immunizer claim filing (influenza/pneumococcal/COVID-19) with limitations

Roster billing definitionRoster billing is a simplified claim filing procedure allowing mass immunizers to submit a roster attached to a single Form CMS‑1450 to bill for multiple beneficiaries for influenza, pneumococcal, and COVID‑19 vaccinations (not available for hepatitis B).

Provider obligationsEntities using roster billing must enroll (CMS‑855) as Mass Immunization Roster Billers, accept assignment, cannot collect payment from beneficiaries, and submit required beneficiary data on rosters.

Roster content requirementsRosters must include provider name/NPI, date of service, patient identifiers, beneficiary signature or on‑file signature, and other minimum data as specified by guidance.

RHC/FQHC vaccine billing — vaccines not billed as visits; cost included in cost report or PPS rates

RHC/FQHC vaccine billing ruleInfluenza, pneumococcal and COVID‑19 vaccines do not count as RHC/FQHC visits; vaccine costs are included in the cost report or PPS rate and a visit is not billed when vaccine is the sole service.

Hepatitis B handlingPayment for hepatitis B vaccine is included in the RHC all‑inclusive and FQHC PPS rate; RHCs/FQHCs do not bill for a visit if vaccine administration is the only service provided.

Reporting for FQHCsIf another reason for the visit exists, FQHCs should report the vaccine and administration codes on TOB 77x for informational/data collection purposes only.

Mass immunizer definition — entities providing group vaccinations

Mass immunizer definitionA mass immunizer is any entity that gives influenza, pneumococcal, or COVID‑19 vaccinations to a group of beneficiaries (e.g., public health clinics, shopping malls, senior centers, health fairs).

Scope limitationMass immunizer roster billing applies to providers other than RHCs/FQHCs and is intended to increase access to preventive vaccinations via group settings.

Enrollment requirementEntities wanting to act as mass immunizers must enroll as the appropriate provider type and meet CMS requirements for roster submission and assignment acceptance.

Centralized billing definition — single contractor submission option for mass immunizations

Centralized billing definitionCentralized billing allows a provider who conducts mass immunizations for influenza and pneumococcal (COVID‑19 centralized billing enrollment ongoing) to send all claims to a single contractor for payment regardless of geographic locality, subject to qualification criteria (e.g., services in multiple localities).

Enrollment pathProviders interested in influenza/pneumococcal centralized billing contact Novitas; COVID‑19 centralized biller applications are ongoing via CMS enrollment resources.

Operational obligationsCentralized billers must accept assignment, submit electronic rosters in approved format, provide beneficiary addresses and processing MAC name in writing, and meet contractor criteria for locality coverage.

CWF edits definition — explanation of Common Working File edits used for duplicate/frequency checks

CWF edits definitionCommon Working File (CWF) performs line‑item edits by beneficiary MBI, MAC number, date of service, vaccine procedure and administration codes to detect and reject duplicate claims; specific influenza/pneumococcal vaccine codes and administration codes (G0008/G0009) trigger rejects.

Reject behaviorWhen a duplicate is detected CWF returns specific reject codes (e.g., '7262' for Part A) and MACs must deny the second claim and issue appropriate remittance messaging (MSN/CARC/RARC).

Crossover editingCWF performs crossover edits for Part B claims by reviewing Part B outpatient claim history to prevent duplicates across contractors and returns specific reject codes for matches.

FDA MQSA file — MQSA certification file referenced for facility verification

FDA MQSA file roleThe FDA provides weekly MQSA certification data to CMS in an 'MQSA file' used by MACs to verify facility certification, film/digital indicators, and effective/expiration dates for mammography facility payment determinations.

Digital vs film indicatorsThe MQSA file includes record types indicating film (1) or digital (2) certification so CMS can determine eligibility for higher digital mammography payment rates.

Certification consequencesIf facility certification is missing, suspended, or revoked per the MQSA file, MACs will deny claims for mammography services per program denial language.

Professional component definition

Professional component definitionThe professional component of mammography is the physician's interpretation of the examination and is billed separately from the technical component; professional payment is based on MPFS where applicable.

Billing formsProfessional components are billed on CMS‑1500; technical components billed on CMS‑1450 (Form CMS‑1450) for institutional claims using appropriate revenue codes.

ModifiersUse modifier -26 to identify the professional component when billing separately; billing rules and payment methods vary by provider type and setting.

Technical component definition

Technical component definitionThe technical component includes all services other than the physician's interpretation (equipment, staff, supplies) and is billed separately using the technical HCPCS/CPT codes and appropriate revenue lines.

Billing forms and revenue codesTechnical component is billed on Form CMS‑1450 with revenue codes (e.g., 0403 for CAH technical component) and may be subject to different payment methodologies depending on provider type.

Modifier usageUse modifier -TC to denote the technical component when billing separately from the professional component.

Global service definition — combined professional and technical component notes and outpatient restrictions

Global service definitionA global mammography service includes both professional and technical components billed together; global billing is not permitted for services furnished in provider outpatient departments except for CAHs electing the optional method for mammography.

CAH exceptionCAHs electing the optional (All‑Inclusive) method may bill global or all‑inclusive lines per CAH guidance (TOB 85X) with specified revenue codes for technical and separate lines for professional component.

Form and setting constraintsGlobal vs separate component billing depends on provider setting and election (e.g., outpatient departments generally must bill components separately).

CAH Optional Method — definition of All-Inclusive Method

CAH Optional Method (All‑Inclusive) definitionThe CAH Optional Method (All‑Inclusive) permits CAHs to elect payment by reasonable costs for facility services and payment at 115% of the allowed amount for the professional component; option effective for cost reporting periods beginning on/after Oct 1, 2001.

Billing under optional methodCAHs electing optional method bill TOB 85X, revenue code 0403 and HCPCS 77067 for the technical component and professional component on separate lines with rev codes 96X/97X/98X.

Effect on payment calculationUnder optional method professional component paid at 115% of allowed amount (resulting in ~92% of lower of charge or MPFS when combined with facility calculation as described).

CAH Standard Method — definition of standard CAH payment method

CAH Standard Method definitionUnder the CAH Standard Method, CAHs bill the technical component on TOB 85X, revenue code 0403 and HCPCS 77067; professional services are billed to A/B MAC (B) and paid under the MPFS.

Payment basisScreening mammography payments under the standard method are based on MPFS or lower of charge depending on MAC and setting; deductible does not apply for screening mammography technical component.

When to useCAHs not electing the optional method follow the standard method billing and payment instructions in guidance.

IDTF definition — Independent Diagnostic Testing Facility and certification requirements

IDTF definitionAn Independent Diagnostic Testing Facility (IDTF) that furnishes any type of mammography service must have FDA/MQSA certification to perform such services; entities performing only diagnostic mammography should not enroll as an IDTF.

PayabilityScreening mammographies performed in/by an IDTF are payable by Medicare when IDTF holds required FDA certification.

Enrollment guidanceRefer to Chapter 35 IDTF guidance for claims processing details and enrollment rules when performing mammography services as an IDTF.

CWF Type of Service — screening vs diagnostic type of service values

CWF Type of Service (screening vs diagnostic)For claims on/after Jan 1, 1998, CWF Type of Service value '1' indicates screening (medical care) and '4' indicates diagnostic radiology — used in CWF edits and processing.

Use in mammography claimsType of Service along with POS and deductible indicator informs CWF age/frequency edits for screening mammography; diagnostic has no frequency limit.

Interaction with trailer recordsTrailer 17 of the Part B Basic Reply record provides the date of the last screening mammography as tracked in CWF for frequency enforcement.

Digital imaging payment provision (BIPA 2000) — payment multiplier for digital imaging tech

Digital imaging payment provision (BIPA 2000)For technologies that directly take digital images, payment equals 150% of the amount otherwise paid for a bilateral diagnostic mammography for the specified modernization period; other provisions apply for conversion technologies with specified add‑ons.

Certification requirementPayment restrictions for digital mammography apply only to facilities meeting MQSA certification requirements for digital imaging as shown in the MQSA file.

Timeframe noteProvision applied to the modernization payment period beginning April 1, 2001 (with specified end dates and hospital OPPS exceptions) and informs payment methodology for digital technologies.

CWF editing parameters — Common Working File parameters for Q0091 edits

CWF editing parameters for Q0091CWF will edit claims containing HCPCS Q0091 using parameters effective July 1, 2005 to enforce frequency and diagnosis criteria (low‑risk every 2 years; high‑risk every year).

Edit triggersCWF uses recognized lists of low‑risk and high‑risk ICD‑10 codes to determine allowable intervals for Q0091 and will reject or deny when criteria are not met.

Specimen resubmission guidanceWhen another specimen is required due to unsatisfactory result, bill Q0091 with modifier -76 for repeat specimen handling as annotated in guidance.

Screening pelvic examination definition — required elements and frequency

Screening pelvic exam definitionA Medicare‑covered screening pelvic exam includes at least seven of eleven listed elements (breast inspection/palpation, digital rectal, external genitalia, urethral meatus, urethra, bladder, vagina, cervix, uterus, adnexa/parametria, anus/perineum) and is covered biennially with exceptions for high‑risk/childbearing conditions.

FrequencyBiennial coverage applies generally (effective July 1, 2001 modifications) though exceptions exist for high‑risk or childbearing‑age beneficiaries requiring different intervals.

Specimen collectionA screening pelvic exam may include specimen collection for smears and cultures and must meet element requirements to qualify for coverage.

PT modifier / screening turned diagnostic — modifier guidance when screening converted to diagnostic

PT modifier / screening turned diagnostic guidanceAppend the -PT modifier when a screening colorectal cancer procedure (G0104, G0105, G0121) becomes diagnostic/therapeutic during the same encounter to identify the scenario for modified cost‑sharing rules.

Coinsurance transitionWhen PT modifier is appended, coinsurance is reduced (CY2023‑2026: 15%; CY2027‑2029: 10%; ≥2030: waived) while deductible is waived; reduction applies to codes meeting the PT criteria.

KX modifier interactionUse KX modifier to identify screening colonoscopy performed following a positive non‑invasive stool test to allow frequency exceptions per program rules.

KX modifier definition — use when colonoscopy follows positive non-invasive stool test

KX modifier definition and useAppend the KX modifier to a screening colonoscopy claim when the colonoscopy follows a positive non‑invasive stool‑based test (e.g., 82270, G0328, 81528) to bypass frequency limitations and allow payment under screening exceptions.

Effective rule referenceThis scenario and KX use is described in 60.2 and 60.3; effective for services furnished on/after Jan 19, 2021 (blood tests) and Jan 1, 2023 for certain frequency rules updates.

Interaction with PT modifierIf the procedure becomes diagnostic/therapeutic during the encounter, bill the appropriate diagnostic code with -PT and follow coinsurance/deductible rules applicable to that scenario.

Policy Summary

PayerUCare

PolicyPreventive and Screening Services (Chapter 18)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionWaiver of cost sharing requires 100% payment for IPPE, AWV, and USPSTF A/B preventive services.

SourceLink

On This Page

G0008	Administration of influenza virus vaccine
G0009	Administration of pneumococcal vaccine
G0010	Administration of hepatitis B vaccine (use for OPPS billing)
Z23	Encounter for immunization (diagnosis for vaccine visits)

Z23	ICD-10-CM diagnosis code for preventive vaccine immunizations
Revenue code 0636	Pharmacy, Drugs requiring detailed coding (vaccine product)
Revenue code 0771	Preventive Care Services, Vaccine Administration

90630, 90653-90658, 90660-90662, 90672-90674, 90682, 90685-90688, 90694, 90756	Influenza vaccine procedure codes subject to CWF duplicate-payment line edits
90670, 90671, 90677, 90732	Pneumococcal vaccine procedure codes subject to CWF duplicate-payment line edits
G0008, G0009, G0010, 90471	Administration codes and linkage for payment rate determination

90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90694, 90756	Influenza virus procedure codes subject to duplicate-claim edits
90670, 90671, 90677, 90732	Pneumococcal procedure codes subject to duplicate-claim edits
G0008, G0009	Administration codes subject to duplicate-claim edits

C50.412	Malignant neoplasm of upper-outer quadrant of left female breast
R92.0	Mammographic microcalcification found on diagnostic imaging of breast
N63.11	Unspecified lump in right breast, upper outer quadrant
Z85.3	Personal history of malignant neoplasm of breast

77063	Screening Digital Breast Tomosynthesis, bilateral (must be billed with primary screening mammogram 77067)
G0279	Diagnostic digital breast tomosynthesis, unilateral or bilateral (must be billed with primary diagnostic mammogram 77065/77066)

77067	Screening mammography (2018+ CPT code; formerly G0202)
77066	Diagnostic mammography, bilateral (2018+ CPT code; formerly G0204)
77065	Diagnostic mammography, unilateral (2018+ CPT code; formerly G0206)

77067	Digital screening mammography (formerly G0202)
77066	Diagnostic mammography (technical component) (formerly G0204)
77065	Diagnostic mammography (professional/technical as applicable) (formerly G0206)