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Medicare Annual Physicals

  1. #1
    Wink Medicare Annual Physicals
    Medical Coding Books
    I am still having the worst time with Medicare to get a physical paid for. I know they will absolutely not pay for diagnosis code V70.0 (annual exam). I have copied his note below for help. I'm not sure that I can use V15.89 to get it paid...

    Mr. XX is a 69-year-old male. He is here for an annual exam.


    Patient complains of annual exam. His last physical exam was 4 years ago. He underwent colonoscopy 1979 years ago with normal results. He's had vision screening done 10 years ago and this was normal.
    Smoking Status: Nonsmoker

    CONSTITUTIONAL: Negative for chills, fatigue, fever, and weight change.
    EYES: Negative for blurred vision, eye pain, and photophobia.
    E/N/T: Negative for hearing problems, E/N/T pain, congestion, rhinorrhea, epistaxis, hoarseness, and dental problems.
    CARDIOVASCULAR: Negative for chest pain, palpitations, tachycardia, orthopnea, and edema.
    RESPIRATORY: Negative for cough, dyspnea, and hemoptysis.
    GASTROINTESTINAL: Negative for abdominal pain, heartburn, constipation, diarrhea, and stool changes.
    MUSCULOSKELETAL: Negative for arthralgias, back pain, and myalgias.
    NEUROLOGICAL: Negative for dizziness, headaches, paresthesias, and weakness.
    HEMATOLOGIC/LYMPHATIC: Negative for easy bruising, bleeding, and lymphadenopathy.
    ENDOCRINE: Negative for hair loss, heat/cold intolerance, polydipsia, and polyphagia.
    PSYCHIATRIC: Negative for anxiety, depression, and sleep disturbances.


    No Known Drug Allergies.

    Current Medications:
    Valtrex 500mg Tablet take one tablet qd



    Current: 2/26/2008 8:56:21 AM
    Ht: 67 inches; Wt: 195 lbs; BMI: 30.54
    T: 98 F (oral); BP: 138/77 mm Hg (left arm, sitting); P: 92 bpm (left arm (BP Cuff), sitting); R: 16 bpm
    VA: 20/50 OD, 20/25 OS (without correction)


    GENERAL: well developed, well nourished, in no apparent distress
    EYES: lids and conjunctiva are normal; PERRLA; EOMI; fundoscopic exam reveals bilateral loss of red reflex, left > right;
    E/N/T: normal external ears and nose;; Ears: left TM is normal; left EAC is normal; right EAC is occluded by cerumen; Hearing Screen: Able to hear fingers rubbed together with both ears; Nose: normal nasal mucosa, septum, turbinates, and sinuses; Lips/Teeth/Gums: gingival edema; white ulcer right lower outer gum with dental caries right posterior molar into gum line Oropharynx: normal mucosa, palate, and posterior pharynx;
    NECK: Neck is supple with full range of motion; thyroid is normal to palpation;
    RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs;
    CARDIOVASCULAR: normal rate; regular rhythm; no murmurs carotids: 2+ amplitude, no bruits; 2+ pedal pulses; no edema;
    GASTROINTESTINAL: normal bowel sounds; no masses or tenderness; no organomegaly rectal exam: normal tone; nontender, guaiac negative stool; guaiac negative stool;
    GENITOURINARY: prostate: no nodules, tenderness, or enlargement;
    LYMPHATIC: no enlargement of cervical nodes; right submandibular node;
    MUSCULOSKELETAL: digits/nails: no clubbing, cyanosis, or evidence of ischemia or infection; normal gait; grossly normal tone and muscle strength; full, painless range of motion of all major muscle groups and joints no masses, effusions, misalignment, crepitus, or tenderness in major joints;
    NEUROLOGIC: cranial nerves: 2-12 grossly intact; normal DTR's elicited in biceps, triceps, supinator, knee, and ankle jerk; sensation: subjectively intact to light touch;
    PSYCHIATRIC: mental status: alert and oriented x 3; appropriate affect and demeanor;

    Lab/Test Results:

    Urinalysis: (-) glucose, (-) bilirubin, (-) ketones, S.G. 1.020, trace blood, pH 6.5, (-) protein, normal (0.2-1 EU) urobilinogen, (-) nitrite, (-) leukocyte esterase; Hemocult: negative;

    Annual exam

    OS: 20/25 (uncorrected);
    OD: 20/50 (uncorrected);

    Cerumen impaction

    Procedure: Cerumen impaction is noted in the right ear. The degree of wax accumulation is moderate in the right ear. With minimal difficulty, using a syringe irrigation, the wax is removed. Removed from ear was hard balls of wax. The patient tolerated the procedure well.
    There were no complications.


    V70.0 Annual exam
    521.07 Dental caries of smooth surface
    366.9 Cataract
    380.4 Cerumen impaction


    Annual exam
    LABORATORY: Labs ordered to be performed today include, CBC, lipid panel, comprehensive metabolic panel, PSA, TSH, and urinalysis.
    REFERRALS: Outside referral to a gastroenterologist ( to perform screening colonoscopy ).

    Collection of venous blood by venipuncture
    Complete (CBC), automated (Hgb, Hct, RBC, WBC, and platelet count) and automated differential WBC co
    Lipid panel (total cholesterol, HDL, triglycerides)
    Comprehensive metabolic panel (Albumin, Bilirubin, Ca, CO2, Cl, Creatinine, Glu, alkaline phosphatas
    Thyroid stimulating hormone (TSH)
    Urinalysis, automated, without microscopy
    Screening visual acuity, quantitative, bilateral

    Dental caries of smooth surface

    Penicillin VK 500mg Tablet Take 1 tablet(s) by mouth bid for 10 days #20 (Twenty) tablet(s) Refills: 0

    Orders: Patient advised to schedule dental appointment ASAP, and agrees to comply.


    Orders: Patient advised to schedule optical evaluation, agrees to comply.

    Cerumen impaction

    Removal impacted cerumen, one or both ears

    Other Orders:
    Blood occult, perioxidase activity, qualitative; feces for colorectal neoplasm screening


    Primary Diagnosis:
    V70.0 Annual exam

    99387 Preventive medicine, new patient, age 65+ years
    36415 Collection of venous blood by venipuncture
    81003 Urinalysis, automated, without microscopy
    REF Referral
    99173 Screening visual acuity, quantitative, bilateral

    521.07 Dental caries of smooth surface

    99202-25 Office/outpatient visit; new patient, level 2

    366.9 Cataract

    380.4 Cerumen impaction

    69210 Removal impacted cerumen, one or both ears

    Other Orders:
    82270 Blood occult, perioxidase activity, qualitative; feces for colorectal neoplasm screening

    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. #2
    Default Debbie-CPC
    Is your claim being denied for the dx or the CPT? We bill "welcome to Medicare" physicals with HCPCS code G0344 and use dx V70.0 and get paid.

  3. #3
    Columbus, Ohio
    I agree with you. I think that the CPT is the reason for denial and not the Dx on the above scenario.

  4. #4
    It's not a Welcome visit - it's just a routine visit and we do not have an ABN signed by him. We will most likely have to eat the bill but I want to make sure all avenues are tried to get it paid first.


    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.

  5. #5
    Medicare does not pay for preventative exams 9938* - 9939*. Or they don't pay for a sick visit 9920* - 9921* with the V70.0 diagnosis
    Last edited by Herbie Lorona; 07-29-2008 at 03:15 PM.
    Herbie W Lorona Jr., CPC, CPC-H

  6. #6
    I know they won't pay for those codes, I just didn't know if anyone else has ever faced this problem and if there was a way to file and get paid. So the reality is that I will pretty much be eating the bill?

    Thank you all

    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.

  7. #7
    Greeley, Colorado
    You do not need to eat the bill...since it is an exclusion from Medicare benefits, you don't have to get an ABN and you can bill the patient. Although, it's nice to get the ABN so the patient knows what's coming. Not a requirement.

  8. #8
    Duluth, Minnesota
    Hey Kristie, I see a few things in the note: We all know Medicare doesn't pay for preventive visits - but you need a .GY modifier on the "new" preventive code - I've never coded an eye exam 99173 separate with a px for MC - you can't have two "new" patient codes for this person so the E/M needs to be an established patient (is that not being paid also, maybe that's why)- I'd go with still a level 2 (99212.25) though because I don't think they really did all that much to support a higher code but I haven't taken the time to score this note out. (you might want to do that first to be sure of it's level, but it has to be est patient).
    I don't see where cerumen removal was done "per the guidelines" - so it appears to me to be ear irrigation only which is included in the E/M - dx 380.4 (no 69210)
    sadly, I don't see any covered dx's for all those labs! (ewwww). Without an ABN for the labs, you will have to write them off. The PSA should be the G-code CPT and screening dx- appears you'll need to use screening dx's for the other labs too -
    However, Lisa is correct - you don't eat the cost of the preventive service, it shouldn't get written off because it's never covered by Medicare (excluding the welcome to MC px's) and the patients are aware of that. It doesn't require an ABN to be signed.
    I'm not sure what you wanted to attach the V15.89 code to?... what's the other specified personal history presenting hazards to health?
    Donna, CPC, CPC-H

  9. Default
    When we bill a medicare patient for a prevent/annual exam and a problem visit, we deduct the cost of the problem visit from the prevent and only bill the patient for the remainder. It just makes it easier for the patient to swallow. This is a policy our facility has. So if the is $140 and the problem visit is $35 the patient would only pay $105. Also, in our policies if we are billing a prevent and a problem visit for the same day/time, we use the new patient codes for each. (GY modifier on the prevent) We do not have a problem in getting the problem visit paid by Medicare.

  10. #10
    Raleigh, NC
    Default Michelle R, CPC
    I will completely agree with Donna & with the post above mine.
    Were I work we would charge the 99397 with modifier GY, and office visit with modifer 25 attached. However, I took a medicare class a year or so ago.
    Per Medicare guidlines MCM15501E - When a physician furnishes a Medicare beneficiary a covered vist, at the same place and on the same occasion as a preventative medicine service,consider the covered visit to be provided in lieu of the part preventative medicine service of equal value to the visit.
    Basically what this means is: The physcian may charge the medicare patient, the amount by which the physician's current established charge for the preventative medicine service exceeds his/hers current established charge for the covered visit.

    I hope this helps!

    Michelle R

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