Part B Insider (Multispecialty) Coding Alert

Published on Tue Jul 05, 2011 PDF

Tip: Obtain Medicare denial so the claim can cross over.

Myth: You can't bill for a preventive visit for a Medicare patient beyond what's included in the "Welcome to Medicare" (WTM) exam or the "Annual Wellness Visit" (AWV).

Truth: Regular Medicare won't pay for a preventive examination except for the WTM exam for a new Medicare patient, as well as an annual AWV--which, as you've probably been explaining to patients all year, is not a head-to-toe physical. But many Medicare patients may have other coverage that will pay for a full preventive visit.

Many offices treating part B patients feel they cannot report the preventive codes to Medicare because they will not be paid. But keep in mind that supplemental policies will often 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. 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.

There are two types of supplemental coverage: a gapfiller, 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. 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 you know Medicare doesn't pay, you should call the secondary insurer to see if it will cover it before asking the patient for money.