Wiki G0101 Denied with Preventive Code

bonnienorth55

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Hi all, I'm hoping to get some clarification on this. We are unsure if we are supposed to bill a patient the fee for G0101 if Medicare is denying due to it not being after the 24 months when billed with a preventive code. Example: We billed 99397 with G0101. Medicare denied G code and patient does not have a supplemental insurance. There has been conflicting information within our clinic where some believe the fee for G0101 should be adjusted from the 99397 fee before billing the patient. Others think the patient should be billed the full amount for both codes. I'm having a hard time finding information on this specific scenario (am only finding how to carve out when Medicare DOES pay on the G code). Any feedback would be greatly appreciated!

Thank you!
 
Hi all, I'm hoping to get some clarification on this. We are unsure if we are supposed to bill a patient the fee for G0101 if Medicare is denying due to it not being after the 24 months when billed with a preventive code. Example: We billed 99397 with G0101. Medicare denied G code and patient does not have a supplemental insurance. There has been conflicting information within our clinic where some believe the fee for G0101 should be adjusted from the 99397 fee before billing the patient. Others think the patient should be billed the full amount for both codes. I'm having a hard time finding information on this specific scenario (am only finding how to carve out when Medicare DOES pay on the G code). Any feedback would be greatly appreciated!

Thank you!
G0101 is a carve-out service from 99397, not an additional service to 99397. In the covered years, Medicare pays for their portion of the exam and the patient pays the remainder. In a non-covered year, the patient pays the full amount of 99397.
 
G0101 is a carve-out service from 99397, not an additional service to 99397. In the covered years, Medicare pays for their portion of the exam and the patient pays the remainder. In a non-covered year, the patient pays the full amount of 99397.
Thank you @nielynco! That was my original understanding but then was going back and forth so much that I started to second guess (which is easy to do in this profession). I had a hard time finding guidelines explaining that specifically, you know of one I would be able to direct my providers too? Thank you again ☺️
 
Thank you @nielynco! That was my original understanding but then was going back and forth so much that I started to second guess (which is easy to do in this profession). I had a hard time finding guidelines explaining that specifically, you know of one I would be able to direct my providers too? Thank you again ☺️
Medicare's "Carve Out" Rule Will Help Compute Your Patient's Fee Published on Fri May 19, 2017 in OB/Gyn Coding Alert covers this topic. Many years ago Medicare expressly published this carve-out rule and ACOG also published a coding document that explains all of the coding combinations and what the fee structure would look like for hypothetical cases. I also prepared a coding sheet back in 2020 which I have attached, but have not updated the Dx codes to ICD10 except for the first example.
 

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Medicare's "Carve Out" Rule Will Help Compute Your Patient's Fee Published on Fri May 19, 2017 in OB/Gyn Coding Alert covers this topic. Many years ago Medicare expressly published this carve-out rule and ACOG also published a coding document that explains all of the coding combinations and what the fee structure would look like for hypothetical cases. I also prepared a coding sheet back in 2020 which I have attached, but have not updated the Dx codes to ICD10 except for the first example.
This is very helpful, thank you again!
 
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