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Thread: Medicare Preventive vs Sick Visit

  1. #1

    Default Medicare Preventive vs Sick Visit

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    Isn't it considered fraudulent to bill a Medicare Preventive (99397) as a Problem-focused visit (99215)? Any suggestions on educating providers would be appreciated!

  2. #2
    Join Date
    Apr 2007
    North Carolina


    Personally speaking...I would not recommend this method. We have a large geriatric population and many of these patients have chronic diseases. Many of our patients schedule visits for maintenance of their meds. If the patient is truly coming in for a routine physical (99381-99397), we educate our patient that this will be a self pay visit. It concerns me that if you were audited by Medicare, depending on the CC and documentation, this could set you up for further scrutiny. If they are coming in for both...then below are the guidelines.

    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.
    There could be covered and noncovered procedures performed during this encounter (e.g., screening x-ray, EKG, lab tests.). These are considered individually. Those procedures which are for screening for asymptomatic conditions are considered noncovered and, therefore, no payment is made. Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.


  3. #3


    I agree with Rebecca. I have talked until I'm blue in the face about this - if it's truly a well visit, it's self pay. Well as Rebecca stated, most eldery patients do have chronic problems which are managed at the same time. Therefore some of my physicians have opted to go with a problem oriented E/M only. When really if it's preventative and problem they could technically bill for both, (preventative to patient, problem to medicare) but hey .... we try right?

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