Wiki Annual Exam for Medicare Patient's

[cedwards]

Our providers are not only doing the pap/pelvic and breast exams. They are also taking vital signs, doing a ROS, PFSH, examining other body systems/areas, counseling, giving anticipatory guidance, etc. The Q0091 and G0101 codes do not capture the additional services the provider is providing. I believe we should be coding the 99391-99397 (preventative services) to the patient as a Medicare Carve out. Any insight?

 

[carafry]

Medicare pxs

If your docs are performing a comprehensive history and exam in addition to the breast and pelvic and the patient is not there to address complaints, I would say by all means, you should be billing a preventive visit. Keep in mind that Medicare will not pay for this visit and you would do best to inform the patients of this before they have their exam - even better to let them know at the time of sheduling. If your physicians are performing less than the comprehensive hx and exam but still more than just the pelvic and breast, you also have the option of billing an E/M code (99212-99214) with a preventive dx code. If the patients do not want to pay for the visit, work with your docs to establish a protocol so that these patients can be seen for just the breast and pelvic exam portion that Medicare will cover. Good luck!

 

[amsmith22]

CMS carve out billing

be sure to check out CMS's site relating to gynecologic screenings and their "carve out" billing policy
example: charge for preventive visit for an established pt age 65 or older (99397) with collection of pap is $230
Medicare's carve out rule requires you to "carve out" the cost of the breast/pelvic exam and the collection of pap. Say you come up with $50 for each G0101 and Q0091. This leaves $130 for 99397. Medicare will never cover this portion of the encounter. Most medicare suppliment policies will not cover it either as they only cover deductible and co-ins for allowed medicare services. Many patients are confused by this logic and informing them of their financial risk ahead of time is crucial.
Also, for CMS compliance purposes, your ABN needs only to state that the collection of pap and the pelvic/breast exam are covered only q2yrs (if low risk) but does not need to include the 99387/97 as potentially being denied because these codes are NEVER payable under medicare rules. Though, as a courtesy and to avoid exhausting collections efforts on the back end, you should inform your patients up front of how much they will owe and why.

Hope this helps