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Thread: Carve-out Charge

  1. #1
    Join Date
    Apr 2007

    Default Carve-out Charge

    AAPC: Back to School
    I've searched this forum, followed links and re-read the IOM-04 and cannot determine if the amount to be billed to a patient undergoing a preventive service which includes a problem-oriented service is the preventive charge - problem oriented charge or the preventive charge - problem oriented allowed amount.

    From the IOM: "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."
    Jenny Berkshire, CPC, CEMC, CGIC

  2. #2
    Join Date
    Apr 2007
    North Carolina


    I like this carriers explanation...Page 36

    The physician may charge the beneficiary, as a charge for the non-covered portion of the service, the amount he/she has established as the charge for the preventive medicine service, less the amount that would be owed by Medicare and the patient for the covered visit. In this example, the physician normally bills $200 for a full preventive service. His/her charge for the 99213 is $53.29, the Medicare fee schedule amount.

    The physician may collect $146.71 from the beneficiary for the preventive service ($200 less $53.29) plus the 20% coinsurance of $10.66 for the covered visit. The patient is responsible for $157.37, and Medicare would pay $42.63.

    Last edited by RebeccaWoodward*; 01-26-2010 at 07:04 AM.

  3. #3


    I brought this same situation up to my providers and both of them said they don't want to do this. What do I do? this is the correct way of billing it and they want to just bill for the pt's chronic conditions done at the same time. Is this ok or should I push the other way?
    Stephanie, CPC, HCS-D

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