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Internal Medicine Coding Alert

Reader Question:

Annual Exam Reimbursement

Published on Thu Nov 01, 2001 Print Friendly and PDF PDF

Question: How can we get reimbursement for a Medicare patient who needs an annual physical exam, stool guaiac for colon cancer screening, EKG and urinalysis?

California Subscriber
 
Answer: When Congress created the Medicare program in the 1960s, preventive medicine services were excluded from coverage by statute. Over the years, as more emphasis has been placed on preventive medicine services, Congress has added coverage for certain preventive or screening and early-detection services. Coverage for these services is contingent upon meeting guidelines that regulate the frequency of Medicare's coverage.
 
A full annual exam (99387 or 99397) remains a service that is excluded by statute from Medicare coverage and for which the patient is fully liable and can be charged your full reasonable and customary fee. Because the service is excluded by statute from coverage, an advance beneficiary notice (ABN) is not necessary nor must this service be billed to Medicare. 
 
Medicare could cover the other services mentioned in your question under certain circumstances and, therefore, you will need to decide if they meet the Medicare coverage guidelines. If you know that your local Medicare carrier will not cover the service or have any doubt that the service may not be covered, you must inform the patient and have the patient sign an ABN prior to providing the service. When billing Medicare for these services, be sure to attach modifier -GA (waiver of liability statement on file) to the CPT codes to notify Medicare that you have obtained an ABN prior to providing the service. This will allow you to bill the patient should Medicare deny the service for frequency limits or for medical-necessity reasons (as would be the case for screening services).
 
In your case, obtain an ABN for the EKG and urinalysis and possibly the fecal-occult blood test if you have any reason to suspect the patient had one in the past year.
 
The stool guaiac for colon cancer screening is a Medicare-covered service and should be billed with G0107 (colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations). Medicare will cover this code once a year for patients 50 years of age or older. Use diagnosis codes V76.41 (screening for malignant neoplasm, rectum) and V76.51 (screening for malignant neoplasm of the colon).
 
If the EKG is for screening only, it would not be covered by Medicare but still must be reported to Medicare, because it is a service that Medicare does cover under some circumstances. It would be billed as 93000-GA (electrocardiogram, routine ECG with at least 12 leads; with interpretation and report-waiver of liability on file) with a diagnosis code of V81.2 (screening for other and unspecified cardiovascular conditions). If the urinalysis is also for screening purposes as part of a routine physical exam, bill it with the appropriate urinalysis code (81000-81020) with the -GA modifier and diagnosis code V81.6 (screening for other and unspecified genitourinary conditions). Before you can use the -GA modifier, you must have a signed ABN in advance for the service you are billing.

Reader Questions and You Be the Coder were reviewed by Kathy Pride, CPC, coding supervisor at Martin Memorial Medical Group in Stuart, Fla.

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