Part B Insider (Multispecialty) Coding Alert

Published on Fri Mar 19, 2010 PDF

Could preventive visits be payable by Medicare?

The Patient Protection and Affordable Care Act (PPACA) continues to mystify Part B providers -- not only due to the media coverage about its provisions, but also because practitioners are unsure of how it will affect Medicare pay. Check out these three Q&As that can help you make sense of the health care reform legislation.

Question 1: I've heard that the new reform includes annual wellness visits for our Medicare patients. Is this accurate?

Answer: Yes. The PPACA includes a provision that offers annual "health risk assessments" for Medicare patients. The visits are annual "unless the patient has their Welcome to Medicare exam that year. In those cases, the health risk assessments begin the subsequent year," says Paul Precht, director for policy and communications with the Medicare Rights Center in New York City.

The health reform bill indicates that the annual wellness examination (which will go into effect next year) is free to the patient -- no coinsurance or deductibles apply.

Question 2: I know the health reform bill offers incentive payments for physicians in health professional shortage areas (HPSAs) and I think I'm practicing in one. How can I confirm that and how do I designate it on my Medicare claims?

Answer: In the past, practices in HPSAs used a modifier to denote that fact, but in many cases, it's no longer necessary to do so. Medicare will adjust your payment accordingly if you provide services in a ZIP code that falls within a pre-designated HPSA county.

However, if you practice in a county not designated as an HPSA but your town is designated as one, you'll have to append modifier AQ (Services provided in an HPSA) to your claims. Visit the CMS Web site to determine whether your location qualifies, and if so, how to bill your MAC (www2.cms.gov/HPSAPSAPhysicianBonuses).

Question 3: The healthcare reform bill included several pay boosts that were retroactive to Jan. 1. When will the fee schedule incorporate those retroactive changes?

Answer: Don't look for the retroactive changes to kick in this  week."There's a complex calculation of a variety of those changes that we are going through to put them together," noted CMS's Amy Bassano during an April 13 CMS Open Door Forum. CMS must prepare before it incorporates the pay boosts, which could take "a month or two," she noted on the call.

Plus: Even after CMS releases the new rates, "We still have our Medicare contractors do extensive tests on those to make sure they are correct, so that takes a little bit of time as well," said CMS's Stewart Streimer on the April 13 call.