Wiki Medicare Annual Exam

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melheffley

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I have a question reguarding our Traditional Medicare patients and their annual exams. I understand that Medicare will only allow 1 pelvic/breast & pap (G0101 & Q0091) per 2 years unless the patient is considered "high risk". Our physicians feel that it is important to follow up with our patients on a yearly basis, as this is the best way to find cancers early. They perform a pelvic/breast exam as well as a Hemmocult test each year. If our patient does not qualify as "high risk" by Medicare, how should we bill the off year? Would we simply be billing a 99214 (or appropriated e/m level) and G0328? This is how the office previously was billing for these services. I am new to this office as well as the billing/coding for OB/GYN. I just want to make sure we are doing things appropriatly.
 
Well from the information that we have recieved hopefully this will be a problem of the past. Starting 1/1/11 Medicare has stated that they will cover a preventive exam every year. There is information about this on the CMS Website.
 
Do you happen to know where I can find the documentation on the new coverage guidelines? I tried searching the Palmetto and CMS site, but came up empty. Thanks!
 
Does the new coverage guidelines include the pelvic and breast exam (G0101 and Q0091)? I was under the impression that they were only covering an annual wellness exam once a year, not the pap and breast exam.

When we perform the pelvic and breast exam for patients without a high-risk diagnosis, we code it the same way as the covered year (using the G and Q code), but the patient pays out of pocket for the services (after signing an ABN of course). If you are billing an E/M visit, what diagnosis are you using? Billing a sick visit would imply that something is wrong with the patient, but you are still only performing the services as a preventative measure. No?

Senia Rascon, CPC, COBGC
 
I get the same impression from the new Medicare codes. It seems to me that these codes would be more useful by the patient's PCP rather than us. I think we will run into the problem of the patient's PCP using that code then us trying to use it again in the same year.

We do have our patient's sign an ABN prior to services and use the G/Q codes. Some of our patient's however do not want to pay for the exam and will avoid the exam in the off year.

We no longer billing the e/m code for this. The prior biling staff in our office was using this technique. They were using a problem diagnosis with this. The patient was comming in for her annual exam (pelvic/breast check, hemmocult, RX refill), but the billers were using any problem diagnosis the patient had (cystocele, rectocele, atrophic vaginitis). The patients did have the condition they were billing with, but were not always being seen for that reason. We did not feel that was correct and stopped it immeditaly when we came in. I just wanted some reassurance that we were correct in not billing a problem e/m for these.
 
Medicare Annual GYN exams

As of 1/1/2011, will Medicare pay for an annual GYN exam rather than every 2 years? What codes should be used? I visited several sites and don't find specific language that states a change from 2 years to annual.
 
The new Medicare Wellness Exam has different criteria than a Well Woman's GYN Exam. It seems the PCP would be more appropriate to perform the new Medicare Annual Exam (G0438). The Medicare Wellness Exam does not include a pap/pelvic.

If a complete, comprehensive Well Woman's Exam is done (most typical), AND a pelvic and pap, we code the age-appropriate Preventive Medicine code (ex 99397), with the G0101 and Q0091 (Pelvic, Pap). We apply the GA modifier to the G0101 and Q0091 since the patient always signs an ABN for those services, and append a GY modifier on the 99397 code since we are expecting Medicare to deny as not-covered and patient responsibility.

Hope that helps!
 
Coding Medicare Annuals has been a challenge for me. We do adjust the charges to the 99397-GY, correct? I have been subtracting the price of the G0101 from the 99397 as I was told that is how to adjust it. And our clinic does not always get an ABN signed, so I can not always add GA onto the G0101 and Q0091. And if the patient comes in annually, we end up writing it off because we cant charge it (because of no ABN being signed).
 
MLTipsword said:
Coding Medicare Annuals has been a challenge for me. We do adjust the charges to the 99397-GY, correct? I have been subtracting the price of the G0101 from the 99397 as I was told that is how to adjust it. And our clinic does not always get an ABN signed, so I can not always add GA onto the G0101 and Q0091. And if the patient comes in annually, we end up writing it off because we cant charge it (because of no ABN being signed).
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Sounds like you are referring to the "carve out" MLTipsword, which is the correct way to carve out the non-covered PE visit.
 
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