Part B Insider (Multispecialty) Coding Alert

Published on Sat Jul 04, 2009 PDF

Obtain Medicare denial so the claim can cross over.

Myth: You can't bill for a preventive visit for a Medicare patient who's past his first 12 months.

Truth: Regular Medicare won't pay for a preventive examination except for the "Welcome to Medicare" exam for a new Medicare patient. But many Medicare patients may have other coverage that will pay for a preventive visit.

Once the 12 months have passed, offices feel they cannot report the preventive codes to Medicare because they will not be paid. But many supplemental policies will cover these preventive services.

Important: In many cases, you can't obtain coverage for a preventive visit from a secondary payer until you receive a denial from Medicare. "If you are contracted with the secondary payer, you have no choice -- you have to bill Medicare," says Laura Colbert Carbonaro, director of central billing operations and contracting with ENT and Allergy Associates in Tarrytown, N.Y. "Be sure you bill Medicare with the appropriate modifier for a noncovered service (GY) and then submit to the secondary carrier along with the Medicare denial. Balance bill the patient if necessary after the secondary adjudicates the claim," she says.

There are two types of supplemental coverage: a gap-filler, which may or may not pay for physicals, and a secondary payer, which may offer more benefits. It is tough to predict whether the patient's secondary payer will reimburse preventive care until you bill the charges, says Jean Pryor, CHAP, CPC, CCS-P, PCS, CPC-I, CIMC, CCP, president of Anderson Medical Billing in Cincinnati, Ohio. "In our area there are 32 companies that sell Medigap plans, so it's difficult to tell whether a patient has a plan that will reimburse the physical."

Medical offices often mistakenly try to collect cash from patients for preventive exams instead of billing Medicare because they assume Medicare won't cover the services.

"If it's something we know Medicare doesn't pay, we will call the secondary insurer to see if it will cover it before we ask the patient for money," says Cindy Block, billing manager with Southern Medical Group in Claxton, Ga. "For example, the Zostavax shot is not covered by Part B, but some secondary insurers will pay for it."