Primary Care Coding Alert

Use separate codes for breast/pelvic exam and Pap smear When your FP provides a well-woman examination to a Medicare patient, be sure to use a combination of CPT and HCPCS codes to receive the fullest possible reimbursement. Filing these claims also involves carving out covered portions of the preventive medicine code to ensure claim compliance. Check out this plan for filing well-woman exams for your Medicare beneficiaries. Carve Out Noncovered Portions of CPT Code For the preventive examination, you-ll choose one of the following codes, says Jan Allen, claims and accounts receivable manager for a three-physician practice in Santa Paula, Calif. New patient: - 99387 -- Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; 65 years and older Established patient: - 99397 -- Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 65 years and older (Note: You-ll use 99387 or 99397 for beneficiaries entitled to Medicare on the basis of age. But patients who receive Medicare due to disability or kidney transplant, for example, may be younger than 65. In those cases, the physician might choose a different preventive medicine code reflecting the patient's age -- such as 99396 if it's an established patient 40-64 years of age.) However, Medicare does not cover these routine exams. For that reason, your practice will have to carve out the covered portions and not charge the patient the entire preventive care fee. To arrive at the amount the practice can collect from the patient: - take the billing price (meaning the usual charge) for the preventive care exam, - subtract the billing prices (meaning the usual charges) for a breast and pelvic exam (G0101, Cervical or vaginal cancer screening; pelvic and clinical breast examination) and collection of a screening Pap smear (Q0091, Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and Result: Charge the patient that amount. For example, if the practice usually charges $150 for a preventive care exam, $50 for G0101 and $25 for Q0091, the practice can collect $75 from the patient in addition to any coinsurance owed on the breast and pelvic exam or screening Pap smear collection. Also, remember to append modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit) to the CPT code. This modifier will allow Medicare to formulate the amount the patient owes on the explanation of benefits [...]