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Medicare Denial - OK here is the situation

  1. #1
    Question Medicare Denial - OK here is the situation
    Medical Coding Books
    OK here is the situation.......

    Pt comes in for her yearly female exam, she is on Medicare. The office does not have her sign an ABN form. The office bills the following codes to Medicare.....99397 (no modifier) and G0101 (no modifier). Medicare eob comes back dening the 99397 for PR-204(not covered,pt resp) and the G0101for CO-119(max benefit). We then billed the claim to Anthem, but Anthem denied the whole claim since Medicare denied the claim. We then wrote off the G0101, but billed the patient for the 99397. Now is a carve out allowed on the 99397, even though Medicare did not pay for the codes billed? Can the patient be billed for the 99397 even if no ABN was signed??

    Any advice would be really appreciated!!!

    Thanks Alot

  2. #2
    99397 is a non covered code per Medicare... I have been told that it is billable to the patient and a non covered item does not require an ABN. We still make a practice of informing the patient just because we do not want to get the patient phone call later and then the patient is upset with the practice.

    Does anyone have a different understanding on this?

    Rhonda Green, CPC
    Rhonda Green, CPC

  3. #3
    North Carolina

    You are correct. Because it is a statutorily non-covered service, it does not require an ABN. However, I do agree with you. I do think the patient should be notified. Too many of our elderly simply do not understand the "rules" of Medicare.

    When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381-99397), consider the covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physician’s current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician’s actual charge for the visit. The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury.


    The link below provides a good explanation of how the "carve out" works...

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