Internal Medicine Coding Alert

Published on Thu Feb 01, 2001 PDF

Question: Are preventive service visits billed the same for commercial insurance carriers as for Medicare? What diagnosis codes would I use?

New Jersey Subscriber

Answer: Reimbursement for preventive service visits depends on the patients policy. The majority of commercial insurance companies pay for one preventive exam per year or they have a dollar allowance (such as $200) that can be applied toward preventive services, according to Kathy Pride, CPC, coding supervisor for Martin Memorial Medical Group in Stuart, Fla. Because policies can vary significantly, Pride recommends internal medicine billing managers contact the insurer and find out if there is well-care coverage before the patient arrives for his or her appointment.

The preventive exam is often covered by a commercial insurer, which reimburses for any sick visit portion of the exam differently than with Medicare carriers, which do not cover preventive exams. If the internist, for example, discusses a chronic condition that the patient has such as diabetes or hypertension or possible signs and symptoms of an undiagnosed condition, that sick visit portion of the service is carved out of the preventive service and billed to the Medicare carrier, which will reimburse it.

If there is a sick visit portion to a preventive visit, we will bill it, says Pride. But many commercial insurers will pay for the preventive visit and deny the sick visit as bundled. Or the insurer may apply the sick visit to the patients deductible, and the patient ends up paying for the entire visit. On the rare occasion when an insurer pays for the sick visit and denies the preventative care service, we bill the patient for the difference using the same policy we do for Medicare patients.

Many services performed during the preventive visit, such as a screening EKG, fecal occult blood test or vaccination, may also be separately billed to a commercial insurer. The CPT code is usually used to report these services to the commercial insurer, not the HCPCS codes usually required by Medicare. The administration of a fecal occult blood test, for example, is reported to Medicare with HCPCS code G0107 (colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations). The same test would be reported to a private payer with 82270 (blood, occult, by peroxidase activity [e.g., guaiac]; feces, 1-3 simultaneous determinations).

Concerning the proper diagnosis code to use, check with your main commercial insurers to determine what diagnosis codes they require. However, V70.0 (routine general medical examination at a health care facility) is commonly used with the preventive visit codes (99395-99397).