Wiki Annual wellness visits w/Commercial ins secondary

Karajag

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I'm looking for some direction on billing OBGYN annual visits. We have a number of patients that have Medicare primary and Commercial ins as secondary. There is some confusion as to whether we should be billing (for example) CPT 99397 to Medicare, which denies, and then it goes to the secondary insurance who typically pays the visit. As another example, we have a patient that came in and CPT 99396 was billed to MCR. MCR denied the claim and forwarded it to the patient's secondary BC plan which placed a balance to the patient co-ins. This is not typical but it is a retiree plan through BC and so I think that may be part of why there is a co-ins. The patient is stating that she never paid before 2021 (when this code was 1st billed), and after review of previous submissions, they billed G0101 in 2013, and then G0439 in 2020 (incorrectly). I would appreciate any assistance regarding this!
 
I'm looking for some direction on billing OBGYN annual visits. We have a number of patients that have Medicare primary and Commercial ins as secondary. There is some confusion as to whether we should be billing (for example) CPT 99397 to Medicare, which denies, and then it goes to the secondary insurance who typically pays the visit. As another example, we have a patient that came in and CPT 99396 was billed to MCR. MCR denied the claim and forwarded it to the patient's secondary BC plan which placed a balance to the patient co-ins. This is not typical but it is a retiree plan through BC and so I think that may be part of why there is a co-ins. The patient is stating that she never paid before 2021 (when this code was 1st billed), and after review of previous submissions, they billed G0101 in 2013, and then G0439 in 2020 (incorrectly). I would appreciate any assistance regarding this!
Medicare NEVER pays on the 993xx codes, so the annual gyn exam should be billed to them with G0101 and possibly Q0091 both with a GA modifier. To get a denial from Medicare, bill the remainder of the visit using 993xx with a -GY modifier (which is telling Medicare you know it is not covered). That way when the claim goes to secondary it will show what Medicare did pay and what it did not pay. Do not expect your normal fee for the 993xx code however, as you are splitting the service between two codes with the gyn exam and Pap collection billed separately. Billing this way has worked for quite a few of my clients in the past.
 
Medicare NEVER pays on the 993xx codes, so the annual gyn exam should be billed to them with G0101 and possibly Q0091 both with a GA modifier. To get a denial from Medicare, bill the remainder of the visit using 993xx with a -GY modifier (which is telling Medicare you know it is not covered). That way when the claim goes to secondary it will show what Medicare did pay and what it did not pay. Do not expect your normal fee for the 993xx code however, as you are splitting the service between two codes with the gyn exam and Pap collection billed separately. Billing this way has worked for quite a few of my clients in the past.
 
Happily I am fully aware that MCR does not pay the 993xx! The GY modifier is what seems to have missing from these previous claims. Thank you for your assistance on this.
 
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