Medicare Well Women Visit

baker09

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When Billing G0101 and Q0091 should we bill 99386 or 99396 , I am new to this practice they are billing 99214-25 with the G and Q codes, however medicare can flag if the 25 modifer is over used

What is the correct billing ?
 
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When Billing G0101 and Q0091 should we bill 99386 or 99396 , I am new to this practice they are billing 99214-25 with the G and Q codes, however medicare can flag if the 25 modifer is over used

What is the correct billing ?

A patient can only have one AWV or annual PE every 365 days, so if the patient has already been seen for a PE or AWV, you can't bill another one within the same year. You'll see this a lot when a patient sees their PCP for the yearly PE and then sees their OBGYN separately for the pelvic and pap. So that's likely the reason the 99214 is being charged out.

HOWEVER, if the pelvic and pap were not done in conjunction with the annual exam, you cannot bill an office visit charge when doing the pelvic and pap. Office visits are for "problem" visits, not preventive care visits. In other words, without a CC, there is no medically necessary reason for an office visit, meaning no office visit charge should be submitted. Obviously if the patient does have an unrelated problem that's addressed during the visit, then the 99214-25 would be billable.

If the patient has already had a yearly preventive exam or AWV, you can only charge G0101 and a pap test code such as Q0091. If the office is routinely billing a 9920x or 9921x with a 25 mod for these visits and no problem or CC exists, then that'd be a big no-no.

The 25 does break the bundle between G0101 and 99214, but that also means that there was a "Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure". I'm guessing the documentation probably doesn't support that in some/quite a few cases. From the outside it looks like something fishy is going on in order to get additional payment because no well visit can be charged, if you know what I mean.
 
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