FQHC billing Welcome to Medicare Visits

stacidawn

Contributor
Messages
13
Location
Salina, KS
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We are billing ICD10 z00.00 with the G0468. We are getting denials from Medicare. Is anyone else having problems with getting paid. Can anyone give suggestions on how to correct this? thanks
 

michellepilcher

Networker
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88
Location
Anchorage , AK
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Maybe this is the issue.
Per Encoder:

An initial preventive physical exam (IPPE) or an annual wellness visit (AWV) is performed in a federally qualified health center (FQHC). This service is payable under the FQHC prospective payment system (PPS). Code G0468 must be accompanied by qualifying visit code G0402, G0438, or G0439. Medical visit codes G0466-G0468 must be reported with revenue code 052X or 0519.
 

stacidawn

Contributor
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13
Location
Salina, KS
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Thank you michellepilcher for responding. We are billing the G0402 with the G0468. I checked and we have the correct revenue code. I was wondering if the diagnosis is making the claim deny. Are there certain dgn codes that can be used?
 

rcj0401

Contributor
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Your diagnosis code is correct, it will depend on what they are eligible for, whether it is the welcome to MCR exam, an annual wellness exam, or a subsequent wellness exam. We use Connex to determine what they are eligible for.
 

Chelle-Lynn

True Blue
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729
Location
Modesto, CA
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This is a common issue with the IPPE and the diagnosis Z00.00. According to CMS guidelines a general rule:

Based on coverage provisions in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services. A review of these regulations confirms the conclusion that most dental service and routine services are not part of the Medicare benefit. Although these services may have been paid previously, new edits may now result in the denial of services that are not covered under Medicare.

The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies.
.


Which in itself if not helpful. So you move on to the guidelines specifically provided for IPPE and it states only the following:

Since CMS does not require a specific diagnosis code for the IPPE, you may choose any appropriate diagnosis code. You must report a diagnosis code.


We have run into trouble with the Z00.00 as well. In the end we contacted the local MAC to help us navigate this issue. It is very frustrating and Medicare is not clear on this rule.
 
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