Avoid Billing Surprises: Know What’s Covered in Preventive Visits

Most patients don’t realize the differences among screening, diagnosis, and treatment. When a patient comes into the office for a preventive visit and it turns into acute care, many patients think their insurance will cover the bill. In actuality, the “free preventive care” that results in a diagnosis or follow-up treatment is not considered a free service (without cost sharing) under the Patient Protection and Affordable Care Act (PPACA).

To keep patients happy by eliminating “surprise” out-of-pocket bills, it is important for providers to be up front with patients about costs before providing acute care services resulting from preventive care visits.

Information is the Best Medicine

According to American Medical Association’s (AMA’s) “CPT Code Pocket Guide: Preventive Services with Cost-sharing Waived,” under the Patient Protection Affordable Care Act (PPACA), the cost-sharing waived (no co-pay or deductible) services for insured patients are:

Preventive services for children 6-36 months

  • 90655, 90460, G0008: Influenza virus vaccine (preservative-free)— intramuscular use
  • 90657, 90460, G0008: Influenza virus vaccine—intramuscular use

Preventive service for individuals age 2+

  • 90732, 90460, 90471, 90472, G0009: Pneumococcal polysaccharide vaccine— subcutaneous or intramuscular use

Preventive services for individuals age 3+

  • 90656, 90460, 90471, 90472, G0008: Influenza virus vaccine (split, preservative-free)— intramuscular use
  • 90658, 90460, 90471, 90472, G0008: Influenza virus vaccine (split)—intramuscular use

Preventive service for children < age 5

  • 90669, 90460, 90471, 90472, G0009: Pneumococcal vaccine—intramuscular use

Preventive service for children age 6+

  • 97802, 97803, 97804, G0270, G0271: Screening and counseling for obesity

Preventive services for adolescents age 12–18

  • 86689, G0432, G0433, G0435: Screening for HIV
  • 90743, 90460, 90471, 90472, G0010: Hepatitis B vaccine (2-dose)—intramuscular use
  • 90744, 90460, 90471, 90472, G0010: Hepatitis B vaccine (3-dose)—intramuscular use

Preventive services for women

  • G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091: Screening PAP test and cervical cancer
  • 99406, 99407, G0436, G0437: Counseling for tobacco

Preventive service for women age 20+

  • 80061, 82465, 83718, 84478: Screening for cholesterol abnormalities

Preventive service for women age 40+

  • 77052, 77057, G0202: Screening for breast cancer (mammography)

Preventive service for women age 65+women age 65+

  • G0130, 77078, 77079, 77080, 77081, 77083, 76977: Screening for osteoporosis

Preventive service for men non-age specific

  • G0102, G0103: Screening for prostate cancer

Preventive service for men age 20–35

  • 80061, 82465, 83718, 84478: Screening for cholesterol abnormalities

Preventive service for men age 35–79

  • 80061, 82465, 83718, 84478: Screening for cholesterol abnormalities

Preventive service for men age 65–75

  • G0404*, G0405*, G0389: Screening for abdominal aortic aneurysm (AAA)

Preventive services for adults

  • G0108, G0109: Screening for diabetes
  • 97802, 97803, 97804, G0270, G0271: Counseling for a healthy diet
  • 86689, G0432, G0433, G0435: Screening for HIV
  • 97802, 97803, 97804, G0270, G0271: Screening and counseling for obesity
  • G0117, G0118: Screening for glaucoma
  • 99408, 99409, G0396, GO397: Screening for alcohol and/or substance abuse

Preventive service for adults age 50–75

  • G0104, G0105, G0106, G0120, G0121, 82270, G0328: Screening for colorectal cancer

Preventive services for individuals non-age specific

  • 90660, 90460, 90473, 90474, G0008: Influenza virus vaccine (live)—intranasal use
  • 90662, 90460, 90471, 90472, G0008: Influenza virus vaccine (split, preservative free), enhanced immunogenicity—intramuscular use
  • G0008, G9141, G9142: Influenza vaccine administration/counseling
  • 90670, 90460, 90471, 90472, G0009: Pneumococcal conjugate vaccine— intramuscular use
  • 90740, 90460, 90471, 90472, G0010: Hepatitis B vaccine (3-dose schedule), dialysis or immunosuppressed patient—intramuscular use
  • 90746, 90471, 90472, G0010: Hepatitis B vaccine—intramuscular use
  • 90747, 90460, 90471, 90472, G0010: Hepatitis B vaccine (4-dose schedule), dialysis or immunosuppressed patient—intramuscular use
  • 99406, 99407, G0436, G0437: Counseling for tobacco

Sources: “CPT Code Pocket Guide: Preventive services with cost-sharing waived,” American Medical Association and amednews.com, “Free Preventive Visit Can End in Sticker Shock for patients.”

2017-code-book-bundles-728x90-01

Latest posts by admin aapc (see all)

4 Responses to “Avoid Billing Surprises: Know What’s Covered in Preventive Visits”

  1. Brandi Tadlock says:

    It’s interesting that 90460 is on a lot of those, but 90461 isn’t. So, you only get free cost-sharing, with single-component pediatric vaccines, then?

  2. Ashley Little says:

    I think so. they do not recognize the 90471 code b/c they only pay a flat fee and not a fee for each component. However, I think commerical insurances reimbursement for each component

  3. Pat Champion says:

    Medicare will not waive the deductible, co-pay and coinsurance when you use the 90000 codes for the flu vaccine for Medicare patients. You must use the Q codes or the patient will be responsible for the flu vaccine.

  4. Gerri says:

    What is not mentioned here is that some of these screenings for example PAP/GYN exam G0101 are limited by frequency so telling a patient this is an approved cost sharing waived service may not necessarily be accurate if in fact it was done the year before w/o a high risk diagnosis.

Leave a Reply

Your email address will not be published. Required fields are marked *