Wiki Office visit + preventative counseling for MEDICARE patient


Princeton, TX
Best answers
I do medical billing for a "weight management" doctor (AKA a primary care physician whose niche is providing weight loss medicines and counseling).
As some of you may know, Medicare does not accept the typical weight prevention counseling codes other commercial carriers accept (99401-99403). Instead, Medicare uses their own code: G0447.
The doctor is aware of this, and recently discovered what an ABN is (the form Medicare patients sign when the doctor is performing a procedure that may get denied).
So, now the doctor wants to bill Medicare the following codes: 99215-25, G0447, and 99401, knowing Medicare will pay for the first two (granted the patient's BMI meets the criteria for G0447), and then collecting $70 from the patients to cover the 99401.
I personally see this as double dipping, especially when it comes to Medicare patients who are not always at a financial advantage. I may be biased because this is a doctor who has done other questionable things to make a quick dollar.
Are there any regulations against billing G0447 and 99401 together? Or is it perfectly acceptable?
I have been scrubbing the claims and removing the 99401 (not realizing what he was attempting to do until I discovered the ABN documents today), so I technically have not seen how Medicare would process these claims if I submitted them as the doctor enters them.
The problem is that the ABN is a moot point in this situation. The Limit on Liability (LOL) (yes, really) applies "only to claims for items and/or services not otherwise statutorily excluded" (Medicare Claims Processing Manual, Chapter 30, p12). This means that when a patient is signing an ABN, they are saying they will pay for items that Medicare may or may not pay for, but the office won't know if it's covered until the claim is processed. ABNs do not apply in cases where Medicare would never pay for the service in the first place, and Medicare will not pay for 99401.
Page 13 also has a very nice note: "If the healthcare provider or supplier knew, or should have known [that a service is not covered], the beneficiary may not be charged for any costs related to the denied item and/or service, including copayments and deductibles." So if the doctor collects any money for 99401? That's fraud.