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Medicare and routine exams

  1. #1
    Default Medicare and routine exams
    Medical Coding Books
    I am having a very hard time getting payment from Medicare for a patient seen for a routine exam. I billed 99214 (25modifier), Q0091, G0101, and 99173 with diagnosis V70.0...Has anyone else had any problems or success stories?

    Please help

    Kristie Stokes, CPC-A

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  2. Default
    Routine exams are billable with the Preventive Medicines codes which are not covered by Medicare. The only "routine" exam that is covered is the Welcome to Medicare physical that is performed within the first 6 months of Medicare coverage.

  3. #3
    Greeley, Colorado
    Q0091 and G0101 need to be reported with one of the following ICD-9 codes to be covered: V76.2, V76.47, V76.49, V72.31, V15.89. Medicare will not cover an E/M with V70.0. Preventive medicine codes (ie 99397) are excluded from Medicare coverage. See if this link helps you


  4. #4
    I agree with Lisa. These codes are for the gyn exam and pap collection. Remember to provide an ABN to the patient to advise her that the gyn exam and pap are only covered by Medicare once every 24 months. With the signed ABN, you should add modifier GA to each code indicating you have advised the patient she may be responsible for payment if she has had these services within the last 24 months. If she meets the hi risk guidelines from Medicare, they will cover the exam and pap yearly, but you must use V15.89 with your diagnoses.

  5. Thumbs up Medicare Preventive
    The Medicare Codes G0101 and Q0091 are billable together with the applicable V code for your PAP.

    If your physician is "truly" doing a preventive exam on a Medicare patient along with their PAP (2 very separate services), which from the earlier know that the preventive exam is a "noncovered" service...then you should report what is actually being provided...hence the Preventive codes for 65 or older (99397, etc.), with your V70.0, expecting it to be denied.

    The key here is: 1. The ABN for both the PAP (q 24 mo.) and the Preventive Exam. 2. The modifier 25 on your preventive code. 3. The modifier GA, showing that you had the ABN signed.

    Medicare will adjust your fee for the preventive service, while covering the
    G0101 and Q0091, leaving the balance on the preventive service billable to the patient.

    It works. It tells an accurate story of what went on in the visit and the patient is made responsible to pay for the services that were requested.

    In a more "perfect" situation, the patient would have some sort of complaint that you could use as a primary diagnosis for the exam, enabling you to bill the E/M code with the modifier 25 and get paid for everything!

    Hope this makes sense.

  6. #6
    Greeley, Colorado
    To add to the discussion, you really need to reduce your normal preventive fee for 99397 by the allowed amounts for G0101 and Q0091, so that the total billed is not more than your usual fee for 99397...

  7. #7
    Duluth, Minnesota
    What code(s) did you use for the 99214.25? I agree with Lisa, 99214 will not be paid with a dx of V70.0 - Hopefully the G0101 met the requirements of the breast/pelvic, inspection/palpation of breasts PLUS 6 of the 10 β€œother” elements for the G0101(often we've found it had not been met per documentation and therefore could not be billed/coded out separately anyway/the docs usually hit 4 or 5 elements but not 6 or more).You're correct in that you'd need a .25 on the E/M if it was an E/M – however, if it was a preventive service you'd need .52.GY modifiers attached to the preventive code, and .GA/.GZ modifier to the G0101 & Q0091 depending on if an ABN was signed or not. The codes we use are as follows:
    assume ABN signed –for breast/pelvic
    99214.25 (problem dx's - ie 401.9/272.4/530.81 etc)
    G0101.GA – V76.2
    Q0091.GA – V76.2
    99173 – V72.0
    On the other hand, IF it was a preventive it would be: assume NO ABN signed for breast/pelvic 65 yr old est pt.
    99397.52.GY – V70.0
    G0101.GZ – V76.2
    Q0091.GZ – V76.2
    99173 – V72.0
    I don't believe an ABN is necessary for the preventive service as it is NOT a Medicare covered service (except the Welcome to Medicare PX)
    Donna, CPC, CPC-H

  8. #8
    Smile A great preventive medicine guide from CMS
    This should answer any questions you have...

    Belinda S. Frisch, CPC, CEMC
    Author of "Correct Coding for Medicare, Compliance, and Reimbursement"

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