Wiki medicare breast exam

[Korbc]

Hello,
I'm struggling to find something definitive on this but for a Medicare person to just have a breast screening/exam only should i charge the G0101? I read that a pelvic exam has to be done in order to charge the code despite knowing that for code z01.419 you don't necessarily need both exams done. Then I read that they wouldn't cover if it was just a problem e/m and i don't think it should be because it's a preventative service but the person before me always charged an office problem e/m for it.
Any guidance would be great and or resources
thank you

 

[Cmama12]

In order to bill G0101 7 out of 11 possible elements would need to be documented. Examination of breasts would be one element. Link to CMS info G0101

 

[Korbc]

In order to bill G0101 7 out of 11 possible elements would need to be documented. Examination of breasts would be one element. Link to CMS info G0101

thanks i've seen that before so how should i charge a medicare prev breast exam only without a pelvic exam since it's a preventative service?

 

[nielynco]

thanks i've seen that before so how should i charge a medicare prev breast exam only without a pelvic exam since it's a preventative service?

There is no breast exam only Medicare code. They will only pay for a routine breast exam once every 2 years when performed in conjunction with the pelvic exam. If the only reason for the visit is the breast exam I would use the appropriate E/M with the reason for the breast exam as the diagnosis. If the breast exam was "routine" then it will not be payable by Medicare (and by the way, Medicare does not require a breast exam in order to have a screening mammogram), and there is no routine breast exam diagnosis so the closest you will come is Z12.3, screening exam for malignant neoplasm of the breast. Oh and the patient will have to pay a copay for this visit so be sure she is educated about what she will be responsible for. The alternative, if she is in fact presenting for a preventive only visit and a breast exam is done at that time, is to bill the preventive code and the patient will be responsible for payment as Medicare generally does not reimburse these codes (but some Medicare Advantage plans might if their policies allow).

 

[Korbc]

There is no breast exam only Medicare code. They will only pay for a routine breast exam once every 2 years when performed in conjunction with the pelvic exam. If the only reason for the visit is the breast exam I would use the appropriate E/M with the reason for the breast exam as the diagnosis. If the breast exam was "routine" then it will not be payable by Medicare (and by the way, Medicare does not require a breast exam in order to have a screening mammogram), and there is no routine breast exam diagnosis so the closest you will come is Z12.3, screening exam for malignant neoplasm of the breast. Oh and the patient will have to pay a copay for this visit so be sure she is educated about what she will be responsible for. The alternative, if she is in fact presenting for a preventive only visit and a breast exam is done at that time, is to bill the preventive code and the patient will be responsible for payment as Medicare generally does not reimburse these codes (but some Medicare Advantage plans might if their policies allow).

this is amazing! so helpful! thank you so much!

 

[Korbc]

There is no breast exam only Medicare code. They will only pay for a routine breast exam once every 2 years when performed in conjunction with the pelvic exam. If the only reason for the visit is the breast exam I would use the appropriate E/M with the reason for the breast exam as the diagnosis. If the breast exam was "routine" then it will not be payable by Medicare (and by the way, Medicare does not require a breast exam in order to have a screening mammogram), and there is no routine breast exam diagnosis so the closest you will come is Z12.3, screening exam for malignant neoplasm of the breast. Oh and the patient will have to pay a copay for this visit so be sure she is educated about what she will be responsible for. The alternative, if she is in fact presenting for a preventive only visit and a breast exam is done at that time, is to bill the preventive code and the patient will be responsible for payment as Medicare generally does not reimburse these codes (but some Medicare Advantage plans might if their policies allow).

do they need to be seen in order to get a referral to get the screening mammogram done?

 

[nielynco]

do they need to be seen in order to get a referral to get the screening mammogram done?

No, Medicare does not require a referral for a screening mammogram. The patient can get one one without a physician order as long as she meets the eligibility criteria. There may be some mammogram providers who have an internal rule that they will not schedule the mammo without a referral, but is it not a Medicare requirement. For instance, I have had mine done every year for the past 15 years and never once was asked for a referral - just made the appointment. The only time is you need a referral is if the exam is to be diagnostic, but even the radiologist can convert the exam from screening to diagnostic during the exam if he/she finds something without going back to the originating physician sending over a referral.

 

[Korbc]

amazing thank you!