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Under section 4106 of the Affordable Care Act, if our program expects that a particular

We recognize that an E&M service may include a United States Preventive Services Task Force (USPSTF) grade A or B service (for example, blood pressure screening). To receive the one percentage point federal medical assistance percentage (FMAP) increase, states are required to cover in their standard Medicaid benefit package all USPSTF grade A and B preventive services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, without cost-sharing. It is up to the state to determine how the billing should occur. In the examples mentioned above, if you consider these USPSTF grade A or B recommended services to be an integral part of the office visit, and they will not be billed separately, the state may continue that billing practice. The state may claim the one percentage point FMAP increase on the office visit only if the primary purpose of the office visit is the delivery of a USPSTF grade A or B service, and not if it is simply a component part of a different billed service. The state should work with providers and payers to ensure that Current Procedural Terminology (CPT) coding and reimbursement practices for preventive medicine services are followed. We wish to confirm that a state must be able to document expenditures claimed on the CMS-64 and we believe the best way to accomplish this is through the billing process.

Supplemental Links:

Date
Topic
Affordable Care Act
Sub Topic
Preventive Services
FAQ ID
92046
FAQ Page
Frequently Asked Questions
FAQ Question
Under section 4106 of the Affordable Care Act, if our program expects that a particular screening be done as part of an Evaluation and Management (E&M) coded visit, how does that relate to CMS coverage expectations? Counseling and verbal screening are often incorporated into an E&M visit. Does CMS require that states have distinct coding and reimbursement rates for physician time spent: 1) measuring blood pressure 2) counseling about alcohol misuse 3) making a referral for BRCA screening 4) discussing breast cancer chemoprevention 5) counseling on breastfeeding 6) prescribing oral fluoride 7) screening for depression 8) screening for intimate partner violence 9) screening for obesity 10) counseling to prevent skin cancer 11) counseling on tobacco cessation