Part B Insider (Multispecialty) Coding Alert

Published on Tue Apr 04, 2006 PDF

6 tips for billing preventive services along with Medicare-covered services

Think you can’t receive reimbursement for annual physical exams and other preventive screenings? Think again!

Medicare may not cover many preventive exams (CPT codes 99381-99397), but you can still bill the patient directly for them. And if you perform the preventive screenings alongside Medicare-covered services such as an evaluation and management (E/M) code, you can bill for both. Experts offer the following tips:

1) Overcome physicians’ reluctance to bill the patient for screenings. “Old school” doctors are reluctant to bill the patient, but “I keep telling them they are doing the work and they need to be reimbursed,” says Lisa Center with Via Christi Health Center in Wichita, KS.

2) Don’t bill a problem-focused E/M when the physician actually performs a preventive visit. Use the “50 percent rule,” advises Rhonda Gudell, a coder with Aurora Health Care in Green Bay, WI. If more than 50 percent of the visit was spent on preventive or related services, then bill a preventive visit. Don’t bill an E/M visit just because the physician examined some long-standing problems or refilled some prescriptions.

“Educate the providers that it is fraudulent to bill an office visit if the appointment is a preventative exam,” instructs Kimberly Engel, coding coordinator with Advanced Healthcare in Germantown, WI. “Medicare does do random auditing in order to see if providers are billing what should be a preventative as an office visit.”

3) Let the patient know up front that Medicare won’t pay for all of a preventive visit, and that it’s an elective service, advises Linda Herrera, MRA analyst with Humana in Kansas City, MO. Tell him approximately how much his share of the cost will be so there are no surprises.

Sign Your Name

Ask the patient to sign a form that says, “I am scheduled today to have an annual physical exam. I understand that if my insurance does not pay for this service I am responsible for payment,” advises Christine DuBois, coding and compliance coordinator for Western Mass Physician Associates in Holyoke, MA.

4) Use the 25 modifier when your physician performs a preventive visit on the same day as a problem-focused E/M. If a patient comes in for a preventive screening visit but turns out to have a problem that requires a separate history, physical exam and medical decision-making, you can bill Medicare or other payors for that E/M services .

Warning: But you should only bill a separate E/M service when the patient had a preventive service and the physician spent a significant amount of time dealing with a problem, Center says.

You can bill the patient for the cost of the preventive service, minus what Medicare pays for the E/M. Make sure to charge your patient the copay for the E/M service. The 25 modifier lets your own system, as well as the carrier’s, know that there was another service, says Gudell.

5) You don’t have to bill Medicare for a preventive screening unless the patient requests it, says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, TN. If you do bill Medicare at the patient’s request, then add the GY modifier to make it clear you know Medicare won’t pay.

6) “Carve out” covered screenings from preventive visits. If a patient comes in for a preventive screening and has a pelvic exam, breast exam and pap smear, then you should bill Medicare for those services, says Gudell. Then bill the patient for your preventive visit fee minus what Medicare paid for those screenings.

Some practices may use the 52 modifier (Reduced services) for the preventive visit code along with the Medicare-covered screening codes such as G0101 for the pelvic and breast exam and Q0091 for the pap smear.