Preventative visit and MCR as MSP

raidaste

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We billed a patient's preventative visit 99397 because she had BCBS primary. Now, of course, we are getting denied by MCR because of that code. We can't change it for MCR because that's not what we billed BCBS. Does anyone know how to get around this?
 

Pam Brooks

True Blue
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Hi, Stephanie. Because you provided and billed out a preventive exam to the primary payer, you cannot automatically re-code it to become a different covered service. Both the IPPE and AWV have documentation criteria that need to be met, and your typical preventive visit may not have satisfied these requirements. My question is this, though? Why did BCBS deny or not pay? Preventive care is (since PPACA) covered at 100%.

Anyway, I feel your pain, and we've had to make some policies around this issue.

If the patient has a commercial carrier as primary and MSP, then when they present for the preventive exam (9939x) they are told that anything not covered by the primary payer will be their responsibility since Medicare does not cover this kind of service. This applies also if there's any problem with their commercial payer coverage.

If the patient wants the Medicare's IPPE or AWV, we first submit to the commercial payer, and then to Medicare, where it's covered if the commercial payer doesn't recognize the AWV (most don't).

But you can't re-code a preventive as an AWV or IPPE unless you are able to show with the documentation at hand that the checklist of things required my Medicare have been covered. That list of requirements isn't usually found in your normal preventive exam, so most of the time you won't be able to do it. And our carrier has come right out to say that if you haven't met the list of requirements, you cannot bill the IPPE or AWV. Sorry I don't have better news.
 

raidaste

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Thanks for the input. I kinda figured that would be the way it goes but it's really a confusing mess.
BCBS did make payment we were just submitting the balance to MCR. More than likely they wouldn't have paid anymore than what BCBS paid I just wanted to make sure this was something that didn't have to be billed.
Your answer helped alot.
Thanks
 
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