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Medicare paying Preventive codes

  1. #1
    Default Medicare paying Preventive codes
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    Our Medicare biller reports that she has been receiving payment from Medicare on preventive exams using the 99385-99397. Since Medicare has changed the coverage codes/rules (now to use AWV and IPPE, etc.), we are wondering why we've received payment on these exams. It seems that all of these claims had illness dx's on them in addition to V70.0 or other wellness exam dx's but the wellness dx's were primary and the illnesses all following. Could that be the reason that Medicare paid for these visits even though we used the preventive codes?

    Has anyone else experienced this? Can you comment on it?

  2. #2
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    Medicare will pay on the Initial or Periodic comprehensive preventive medicine evaluations using either the 99385-99397 codes or the G0438 or G0439 codes as long as the primary diagnosis code is V70.0. Be aware that this is the new Annual Wellness Visit and not an actual comprehensive physical exam. This visit is basically a personal history and establishment of screening schedule along with height, weight, blood pressure and BMI measurements. It does not include an actual physical exam. But they will allow the same payment under either set of codes.

  3. #3
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    this is the first i've ever heard that medicare is paying for the 993XX codes. i looked on the fee schedule and they are still listed as indicator N which means its a noncovered service so i'm surprised that you are getting paid. if you are, i think its an oversight.
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer
    Previous AAPC Local Chapter President & VP

  4. #4
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    Quote Originally Posted by ajs View Post
    Medicare will pay on the Initial or Periodic comprehensive preventive medicine evaluations using either the 99385-99397 codes or the G0438 or G0439 codes as long as the primary diagnosis code is V70.0. Be aware that this is the new Annual Wellness Visit and not an actual comprehensive physical exam. This visit is basically a personal history and establishment of screening schedule along with height, weight, blood pressure and BMI measurements. It does not include an actual physical exam. But they will allow the same payment under either set of codes.
    I have not heard of Medicare paying for the 99385-97 codes, do you have a memo or transmittal for this? Also from the Med Learn Matters article on the AWV it is a bit more than what you have stated, it includes assessment of cognitive impairment and functional abilities, and Medicare uses the term preventive exam and AWV as interchangeable terms all related to the G0438 or G0439 codes. I really would hesitate to tell doctors this is not a physical exam. How else will they assess function ability and cognitive impairment?

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    Quote Originally Posted by mitchellde View Post
    I have not heard of Medicare paying for the 99385-97 codes, do you have a memo or transmittal for this? Also from the Med Learn Matters article on the AWV it is a bit more than what you have stated, it includes assessment of cognitive impairment and functional abilities, and Medicare uses the term preventive exam and AWV as interchangeable terms all related to the G0438 or G0439 codes. I really would hesitate to tell doctors this is not a physical exam. How else will they assess function ability and cognitive impairment?
    My information came from a flyer Ingenix had made up regarding the Medicare Preventive Services, and they included the 99385-99397 codes as covered. Of course when I tried to trace back thru their footnotes for where the info came from, I do not find these codes in the actual Medicare guidelines. They are covered under Medicare Advantage plans, so perhaps that is where the confusion lies.

    Assessment of cognitive impairment is mental functioning, functional abilities and safety is also mostly just a question and answer session (it indicates they can use a questionaire) of what they are able to do for themselves.

    Physicians can make their own determination of what might be missing from the list of Medicare requirements and what they normally do in a complete annual physical exam.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  6. #6
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    Quote Originally Posted by ajs View Post
    My information came from a flyer Ingenix had made up regarding the Medicare Preventive Services, and they included the 99385-99397 codes as covered. Of course when I tried to trace back thru their footnotes for where the info came from, I do not find these codes in the actual Medicare guidelines. They are covered under Medicare Advantage plans, so perhaps that is where the confusion lies.

    Assessment of cognitive impairment is mental functioning, functional abilities and safety is also mostly just a question and answer session (it indicates they can use a questionaire) of what they are able to do for themselves.

    Physicians can make their own determination of what might be missing from the list of Medicare requirements and what they normally do in a complete annual physical exam.
    Traditional Medicare does not cover a "preventive wellness" visit. This is/has been a standard policy.


    30.6.2 - Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service. (Rev. 1, 10-01-03)

    See Chapter 18 for payment for covered preventive services.

    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.

    http://www.cms.gov/manuals/downloads/clm104c12.pdf

  7. #7
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    Quote Originally Posted by RebeccaWoodward* View Post
    Traditional Medicare does not cover a "preventive wellness" visit. This is/has been a standard policy.


    30.6.2 - Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service. (Rev. 1, 10-01-03)

    See Chapter 18 for payment for covered preventive services.

    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.

    http://www.cms.gov/manuals/downloads/clm104c12.pdf
    Yes I know, this is additional information that has come out due to the preventive services that ARE now covered. Sorry for my confusion with the information I got from Ingenix....
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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