Preventive services for older adults: recommendations and Medicare coverage.
In 1965, Medicare was originally designed to cover acute illness and short-term rehabilitation; routine physicals and preventive screenings were not covered at that time. The Medicare law (42 USC 1935y, Sec. 1862) explicitly stated, and still states categorically, that Medicare unless specifically provided for, does not cover items and services "not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." (1)
Over the past 30 years, because of the evolving importance and acceptance of preventive medicine, several exceptions providing for specific preventive services were subsequently added to the covered benefits of Medicare Part B for our senior outpatients (note: unless otherwise specified all items discussed in this article apply to Medicare Part B outpatient coverage only). Medicare first began covering preventive services in 1981 with the pneumococcal vaccination. The Balanced Budget Act (BBA) of 19972 added cervical, breast, colorectal, and prostate cancer screenings, diabetic supplies, and osteoporosis screening. The Medicare Modernization Act (MMA) of 2003 (3) further expanded covered preventive services by including the "Welcome to Medicare" exam and cholesterol and diabetes screenings. The Deficit Reduction Act of 2005 added an aortic aneurysm (AAA) screening benefit. (4) Most recently, the Patient Protection and Affordable Care Act of 2010 added an "Annual Wellness Visit" under Medicare effective 2011. (5,6) Consequently Medicare now pays for most commonly performed cancer and other screenings in accordance with the recommendations of the American Cancer Society (ACS) (7) and US Preventive Services Task Force (USPSTF, http://www. uspreventiveservicestaskforce.org/) and in fact is now mandated to pay for all preventive services rated "A" and "B" by the USPSTF with no deductibles or coinsurance. (8) Most other commercial insurance plans will also face the same requirements, however this discussion is limited to Medicare-age older adult patients (i.e. over 65). Each of the Medicare covered preventive services, listed in Table 1, will be discussed in some detail.
For additional information, Medicare's official "Medicare Claims Processing Manual" Chapter 18 (www.cms.gov/manuals/ downloads/clm104c18.pdf) (5) and other pages on Medicare's web site (www.medicare.gov) provide the most current and complete information on Medicare's benefits, guidelines and coverage information for both providers and the public/beneficiaries.
Cervical cancer screening, including Pap smear and pelvic exam, has been covered by Medicare since 1990. The scheduleallows for an exam every 2 years for average-risk individuals. High-risk women may receive a Pap test and pelvic exam every 12 months. It should be noted that current USPSTF guidelines suggest discontinuing screening among women aged 65 years or older who have had adequate screening and are not otherwise at high risk. (9)
Breast cancer screening has been covered by Medicare since 1991. Mammography screening for breast cancer is covered every 12 months for women older than 40. A single baseline examination is permitted for beneficiaries aged 35 to 39. While ACS and USPSTF recommend mammography every 1-2 years after age 40 or 50, it should be noted that upper age limits are poorly defined for this and all cancers. For the very elderly, with only a few years' life expectancy (e.g. over age 85), it is reasonable to decrease or discontinue most routine screenings. (10)
Colorectal cancer screening has been covered by Medicare since 1998. Tests may include fecal occult blood testing (FOBT), screening sigmoidoscopy, or colonoscopy or barium enema (BE). For beneficiaries over 50, FOBT is covered once per year. Sigmoidoscopy is covered once every 4 years. Colonoscopy is covered once every 10 years for average-risk individuals and once every 2 years for high-risk individuals. Barium enema may be substituted for sigmoidoscopy or colonoscopy if the physician judges it more appropriate or accessible; it is covered every 4 years for average-risk individuals and every 2 years for high-risk patients. Newer methods such as CT colonograpy and fecal DNA testing are not routinely covered. These recommendations are consistent with ACS and USPSTF guidelines which also note that routine colorectal cancer screening may be reconsidered after age 75 and discontinued after age 85. (11)
Prostate cancer screening. A digital rectal exam and PSA blood test are covered in all men aged 50 and older once every 12 months. HCPCS Code G0103 should be used when ordering the PSA test for prostate cancer screening, and a digital rectal exam may be billed separately using HCPSCS Code G0102. It should be noted that American Cancer Society Guidelines suggest men over 50 should be offered prostate cancer screening but only with a life expectancy of greater than 10 years and with understanding of the risks and uncertainties of such testing. (7) Similarly the USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for prostate cancer using PSA and in fact states "do not screen for prostate cancer in men age 75 years or older (Grade D recommendation)." (12)
Other Screening Tests
In addition to cancer screenings, Medicare now covers several other screening tests, specifically for cardiovascular disease, diabetes, glaucoma, and osteoporosis.
Cardiovascular disease screening refers to a cholesterol/lipid profile rather than tests for actual cardiovascular disease such as an ECG or stress test, though a screening ECG may be ordered in association with the Initial Preventive Physical Examination (vide infra). A lipid panel blood test, and/or total cholesterol, high-density lipoproteins (HDL), and triglycerides ordered separately, are covered once under Medicare Part B every 5 years in accordance with the National Cholesterol Education Program (13) which recommends a cardiovascular and risk factor evaluation every 5 years in all asymptomatic adults over age 20. Other cardiovascular tests remain noncovered for routine screening in asymptomatic patients. It should be noted that the value of cholesterol screening and treatment is controversial in elderly individuals. (10)
Diabetes screening includes fasting or postprandial plasma glucose for any individual at risk for diabetes (including anyone older than 65). Individuals with prediabetes may be tested twice per year, and those without prediabetes may be tested once per year. Diabetic testing supplies, therapeutic shoes and inserts, and insulin pumps are also now covered, along with diabetes self-management training and medical nutrition therapy. Note that although the American Diabetes Association does recommend routine screening for type 2 diabetes for anyone over 45, particularly if overweight or obese, (14) the USPSTF concluded that the evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose. However the USPSTF provided a "grade B" recommendation for type 2 diabetes screening for adults with hypertension or hyperlipidemia (http://www. uspreventiveservicestaskforce. org/uspstf/uspsdiab.htm).
Glaucoma testing, including an eye exam and intraocular pressure measurement, is covered by Medicare once every 12 months for beneficiaries at high risk for glaucoma, people with diabetes, or anyone with a history of glaucoma. This examination must be done under the supervision of an optometrist or ophthalmologist, not by a primary care physician. The USPSTF found insufficient evidence to recommend for or against screening adults for glaucoma (http://www. uspreventiveservicestaskforce. org/uspstf/uspsglau.htm).
Osteoporosis screening via bone mass measurements covered by Medicare include FDA-approved radiologic procedures (e.g., DEXA scan) to evaluate bone density in estrogen-deficient women at clinical risk for osteoporosis (i.e. all older women). Other eligible risk groups include any individual with vertebral abnormalities, receiving long-term steroid therapy, or being treated and monitored with an approved osteoporosis drug. Bone density tests are generally covered once every 24 months, more often if medically necessary. The USPSTF recommends that all women aged 65 and older should be screened routinely for osteoporosis (grade "B" recommendation) however the task force concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men (http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm). (8)
Abdominal Aortic Aneurysm screening is the most recently implemented Medicare screening benefit, effective 2007. The Deficit Reduction Act of 2005 provided for Medicare coverage of a 1-time AAA ultrasound screening, which must be ordered at the time of the IPPE.4 Beneficiaries must be males aged 65 to 75 and must have smoked at least 100 cigarettes or manifest other risk factors, as recommended by the USPSTF (grade "B" recommendation). (8)
Medicare Part B now covers three recommended adult immunizations--influenza, pneumococcal, and hepatitis B. Any and all other federally recommended vaccinations are covered under Medicare Part D since 2008. Pneumococcal vaccination has been covered for all Medicare beneficiaries over 65 since 1981. One pneumococcal vaccination for patients over age 65 is generally considered to provide sufficient coverage for a lifetime, but Medicare will also cover a 1-time booster vaccine for high-risk persons if 5 years have passed since their last vaccination, in accordance with current CDC guidelines. (15) Influenza vaccination has been covered by Medicare since 1993. Vaccination is covered once every year or flu season. Current guidelines recommend immunization of all adults 50 years and older and all healthcare workers. For both influenza and pneumococcal vaccination, there is no deductible, coinsurance, or copayment required, and both the cost of the vaccine and administration by providers is covered. Other services and procedures may be provided and billed the same day without any modifiers necessary. Note that the intranasal influenza live-attenuated vaccine is only recommended for persons 49 and younger and so is not appropriate or covered for Medicare beneficiaries; adults over 65 may receive either the standard influenza vaccine or the high-dose (Fluzone) influenza vaccine. (15)
Since 1984, hepatitis B vaccination has also been covered for Medicare beneficiaries considered to be at high risk for the disease (those with end stage renal disease or hemophilia, immunosuppressed patients, homosexual men, and residents of institutions for the mentally handicapped). Neither hepatitis A nor hepatitis B vaccinations are generally recommended for routine use in adults in the absence of high-risk indications. (15)
Somewhat surprisingly, tetanus vaccination was not routinely covered by Medicare even though it has long been recommended every 10 years for all persons of all ages after an initial primary series usually given in childhood. Patients should be made aware that they may have to pay for routine tetanus boosters out of pocket, however, tetanus vaccination, when administered as part of treatment for an injury or potential exposure, should always be covered by insurance. Since 2008, tetanus immunization should be covered under Medicare Part D when not covered by Part B. Tetanus-diphtheria (Td) combined vaccine is usually recommended for adult booster vaccination and as a primary series for those who have not been previously vaccinated. The newer Tdap vaccine (tetanus, diphtheria and acellular pertussis) is also now approved for adults 65 and over in substitution for one booster or primary series dose if not received before. (15)
In October 2006, the CDC's Advisory Committee on Immunization Practices (ACIP) recommended all adults over 60 receive one dose of the new shingles (herpes zoster) vaccine (Zostavax) and the FDA has since approved the vaccine for adults over 50 as well. (16) This vaccination is more than 60% effective in preventing shingles and post-herpetic neuralgia and is thus quite worthy of consideration, though under used because of the somewhat confusing coverage. This vaccine, which costs about $150-200, is not covered by Medicare Part B but rather by Part D Prescription Drug Plans (PDP's) which reimburse pharmacies rather than physicians. Exact costs/copays must be verified by the pharmacy with each patient's individual plan. Physicians may purchase and store the vaccine (which must be frozen until used), then bill the managed care plan if covered or bill the patient, who then can try to get reimbursed by the PDP. Alternatively, physicians may give the patient a prescription to obtain the vaccine from a pharmacy, which itself may then bill the patient or be reimbursed by the PDP. The vaccine then will have to be delivered to the physician's office for administration, unless able to be given directly by a qualified nurse or pharmacist directly in the pharmacy. Although Medicare Part B does not pay for the vaccine itself, an administration fee may be charged if injected in the physician's office or clinic. Other than the tetanus and zoster exceptions discussed, all the other aforementioned vaccines continue to be covered by Medicare Part B as in the past. Non-Medicare insurance plans may have their own varying rules.
The complete current list of recommendations for adult vaccinations may always be found on the following web site: http://www.cdc.gov/vaccines/ recs/schedules/adult-schedule. htm#print. The Annals of Internal Medicine also publishes the latest CDC vaccination guidelines yearly. (15)
Initial and Annual "Physicals"
In addition to the aforementioned specific screenings and vaccinations, Medicare Part B now covers two new types of routine physicals, though these are considerably different than the "annual physical" typically conducted by physicians. Other than the Initial Preventive Physical and Annual Wellness Visit Medicare covers no other periodic or routine examinations (i.e. those provided in the absence of symptoms).
The Initial Preventive Physical Examination (IPPE, also known as the "Welcome to Medicare" exam), was established in 2005 subsequent to the Medicare Modernization Act of 2003. This optional exam, covered only once per beneficiary per lifetime, must be performed during the first 12 months (formerly 6 months) of Medicare Part B coverage (i.e. usually at 65-66 years old). This exam includes several mandatory elements: a comprehensive medical and social history, review of risk factors for depression, functional and safety assessment, a focused physical exam including height, weight, blood pressure and visual acuity, and education and counseling regarding any issues identified in the previous elements and regarding other available preventive services under Medicare. The IPPE may be performed by a physician or qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist). The healthcare common procedure coding system (HCPCS) code G0344 is used for the IPPE; and code G0366 is used for an associated ECG tracing, interpretation, and report (no longer required but still optionally covered). Other covered preventive services listed above, and if appropriate, other medically necessary evaluation and management (E/M) services, may be performed and billed at the same visit using modifier -25. Other than the IPPE and Annual Wellness Visit (see below), routine or annual physicals are not covered by Medicare Part B, despite the existence of an appropriate CPT code 99397 and the need to see patients regularly to perform all the above mentioned tests. Due to the numerous specific requirements of this Initial Preventive Visit and the Annual Wellness Visit, it is advisable to use prepared templates to be sure all included elements are completed. (17) Both the IPPE and AWV have been under utilized and criticized by physicians as being unorthodox compared to the expectations of a traditional "annual physical" and thus of dubious utility (18)
The "Annual Wellness Visit" (AWV) is another new type of routine/ annual examination established by the ACA beginning 2011.6,19 This optional visit may be performed one year after the IPPE and then annually. Rather than a routine physical it is a compilation of geriatric and risk factor assessments, culminating in "personalized prevention plan services" (PPPS). The following components must be included, again preferably via a preprinted template: Updated medical and family history, list of current providers and suppliers of medical care and equipment, height, weight, blood pressure and other measurements as deemed appropriate, detection of cognitive impairment and depression, and review of functional ability and level of safety. A list of risk factors and scheduled preventive services and referrals should then be produced for the patient. End of life counseling is a controversial optional component of both the IPPE and AWV. Code G0438 is used for the AWW + PPPS. Both the IPPE and AWV carry an average payment of about $150 as of 2011. Changes in Medicare reimbursement rates and possible legal challenges to the Patient Protection and Affordable Care Act of 2010 are still pending as of this writing (Dec. 2011).
In conclusion, Medicare has appropriately evolved with modern medical practice to include most commonly recommended preventive screenings and vaccinations. Of course, virtually any test or examination may be done and billed to Medicare when medically necessary and accompanied by a relevant diagnosis. However routine physicals or any routine or screening tests other than those specifically discussed above and listed in Table 1 are NOT covered. Clinicians and patients should take advantage of these new and evolving Medicare-covered benefits to foster preventive health at any age.
Upon completion of this article, the reader will be able to:
1) Counsel older adult patients on which preventive services are recommended by the U.S. Preventive Services Task Force and which are covered by Medicare.
2) Individualize preventive care for elderly patients based on age, gender, individual risk factors and preferences.
3) Perform an Initial Preventive Physical Examination and Annual Wellness Visit including Medicare's required components.
31. Medicare now covers an annual physical examination. a. True
32. Aortic Aneurisym screening is covered by Medicare in all male smokers at any time.
33. Medicare covers annual pap smears in all elderly women.
(1.) Social Security Administration. Social Security Act 42 U.S.C. 1395y, Section 1862. Available at: www.ssa.gov/OP_Home/ ssact/title18/1862.htm. Accessed 3 Dec. 2011.
(2.) Centers for Medicare and Medicaid Services. Legislative summary: Balanced Budget Act of 1997 Medicare and Medicaid provisions. Available at: https://www.cms. gov/demoprojectsevalrpts/downloads/ cc_section4016_bba_1997.pdf. Accessed 3 Dec. 2011.
(3.) Emmer S, Allendorf L. The Medicare Prescription Drug Improvement and Modernization Act of 2003. J American Geriatr Soc 2004;52:1013-1015.
(4.) Centers for Medicare and Medicaid Services. Implementation of a one-time only ultrasound screening for abdominal aortic aneurysms (AAA) resulting from a referral from an Initial Preventive Physical Examination. Available at: www.cms.hhs. gov/MLNMattersArticles/downloads/ MM5235.pdf. Accessed 3 Dec. 2011.
(5.) Medicare Preventive and Screening Services. Summary of Changes, May-June 2011. https://www.cms.gov/transmittals/ downloads/R2233CP.pdf . Accessed 3 Dec. 2011.
(6.) Centers for Medicare and Medicaid Services. MLN Matters MM7079, Feb. 2011. Annual Wellness Visit, Including Personalized Prevention Plan Services (PPPS). https://www.cms.gov/ MLNMattersArticles/downloads/MM7079.pdf. Accessed 3 Dec. 2011.
(7.) Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States 2012: a review of current American Cancer Society screening guidelines and current issues in cancer screening. CA Cancer J Clin 2012;62:129-142. Available at: http:// onlinelibrary.wiley.com/doi/10.3322/ caac.20143/pdf. Accessed 31 March 2012.
(8.) US Preventive Services Task Force. USPSTF A and B Recommendations. http://www.uspreventiveservicestaskforce. org/uspstf/uspsabrecs.htm. Accessed 3 Dec. 2011.
(9.) Vesco KK, Whitlock EP, Eder M, Burda BU, et al. Risk factors and other epidemiologic considerations for cervical cancer screening: a narrative review for the USPSTF. Ann Int Med 2011;155:698-705. Available online at www.annals.org. Accessed 4 Dec. 2011.
(10.) Goldberg TH, Chavin SC. Preventive medicine and screening in older adults. J Am Geriatr Soc. 1997;45(3):344-354. Update: J Am Geriatr Soc. 1999;47(1):122 123.
(11.) U.S. Preventive Services Task Force. Screening for colorectal cancer: USPSTF Recommendation Statement. Ann Int Med 2008;149:627-637. Available online at www.annals.org, accessed 4 Dec. 2011.
(12.) U.S. Preventive Services Task Force. Screening for prostate cancer: USPSTF recommendation statement. Ann Int Med 2008;249:185-191. Available online at www.annals.org, accessed 4 Dec. 2011.
(13.) National Cholesterol Education Program. Detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Available at: www.nhlbi.nih.gov/guidelines/cholesterol/index.htm, accessed 4 Dec. 2011.
(14.) Patel P, Macerollo A. Diabetes Mellitus: Diagnosis and Screening. Am Fam Physician. 2010;81(7):863-870. Available online at http://www.aafp.org/ afp/2010/0401/p863.html. Accessed 4 Dec. 2011.
(15.) Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2012. Ann Intern Med 2012;156:211-217. Available at: http://www.annals.org/ content/156/3/211.full. pdf+html?sid=a4c04950-86b8-4d09-87f84f7ae4bccb27. Accessed 31 March 2012. Note: latest immunization schedules always available at www.cdc.gov.
(16.) Centers for Disease Control and Prevention. Update on Herpes Zoster Vaccine: Licensure for Persons Aged 50 Through 59 Years. MMWR November 11, 2011 / 60(44);1528-1528. Available online at http://www.cdc.gov/mmwr/preview/ mmwrhtml/ mm6044a5.htm?s_cid=mm6044a5_w. Accessed 4 Dec. 2011.
(17.) Card RO. Getting paid: how to conduct a "Welcome to Medicare" visit. Fam Pract Manag 2005;12(4):27-31. Available online at http://www.aafp.org/fpm/2005/0400/p27. html. Accessed 4 Dec. 2011.
(18.) Fiegl C. Medicare's missed checkups: Few seniors get wellness exam. AMedNews. com, 2 May 2011. http://www.ama-assn. org/amednews/2011/05/02/gvsa0502.htm. Accessed 4 Dec. 2011.
(19.) American College of Physicians Center for Practice Improvement & Innovation. Annual Wellness Visit. Available online at http://www.acponline.org/running_practice/ practice_management/payment_coding/ medicare/annual_wellness_visit.htm. Accessed 4 Dec. 2011.
Todd H. Goldberg, MD, CMD, FACP
Associate Professor and Geriatrics Program Director, Department of Internal Medicine, WVU Health Sciences Center, Charleston Division & Charleston Area Medical Center, Charleston
Table 1. Summary of Medicare Covered Preventive Services * One-time "Welcome to Medicare" Examination (IPPE) (First 12 months on Medicare Part B only) * One-time aortic aneurysm screening (male smokers 65-75 only, must be ordered at IPPE only) * Annual Wellness Visit (Starting 2011; must be at least 1 year after above) * Cardiovascular screening blood tests (lipid profile) * Cancer tests: Breast cancer screening (mammography) Pap smear and pelvic examination Colorectal cancer screening (FOBT, sigmoidoscopy, colonoscopy or BE) Prostate cancer screening (DRE and PSA) * Bone mass measurements * Diabetic screening, supplies, self-management training * Medical nutrition therapy for individuals with diabetes or renal disease * Glaucoma tests * Smoking cessation counseling * Alcohol misuse counseling * Depression screening * HIV screening (in pregnant women, anyone at risk or who requests testing) * Vaccinations: Influenza Pneumococcal Hepatitis B (Hemophilia, ESRD or immunosuppressed patient) Zoster/Shingles (Medicare Part D) Note: All items covered by Medicare Part B unless otherwise noted. The Affordable Care Act requires Medicare and other insurance plans to cover all preventive services rated "A" or "B" by the USPSTF (Ref. 8) but only those in this list are applicable/covered in the Medicare age group. For additional information and the latest complete list of Medicare covered preventive services, see Ref. 5 and www.medicare.govhttp://www.medicare.gov/navigation/manage-your-health/ preventiveservices/preventive-service-overview.aspx.
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|Title Annotation:||Scientific Article: Special Issue|
|Author:||Goldberg, Todd H.|
|Publication:||West Virginia Medical Journal|
|Date:||May 1, 2012|
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