American College of Physicians: Internal Medicine — Doctors for Adults ®

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How to bill Medicare for prevention-related care

From the May 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: Will Medicare pay for a medically necessary service provided during the course of a comprehensive preventive examination?

A: Medicare will pay for the evaluation and treatment of an acute illness or the ongoing treatment of a chronic condition provided during the course of a comprehensive preventive examination. CPT 2000 states:

"If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201-99215 should also be reported."

Medicare requires that you bill the appropriate outpatient evaluation and management (E/M) service code and the preventive medicine service code that corresponds with the beneficiary's age (in most instances, CPT 99387 or 99397). The extent of the history, examination and medical decision-making involved in treating the symptoms and/or diagnosing conditions associated with the acute or chronic problem determines which office/outpatient E/M service code you select. The office/outpatient E/M service codes describe the portion of the visit that is covered and reimbursable by Medicare. You should check with your Medicare carrier to see if it restricts which office/outpatient E/M service code you can bill in conjunction with a preventive medicine service code. Your carrier, for example, may prohibit you from using the highest office/outpatient E/M service code, Current Procedural Terminology (CPT) 99205 and 99215.

Medicare will deny payment for the preventive medicine service code because the law prohibits the program from paying for a comprehensive preventive examination. Medicare requires you to use a formula to determine how much to bill the beneficiary for the non-covered preventive portion of the visit. You should bill the beneficiary your established charge for the comprehensive preventive examination, less the Medicare allowable for the Medicare covered, medically necessary portion of the visit. The following example is helpful:

You evaluate and treat a 70-year-old beneficiary's hypertension that you detect during a comprehensive preventive examination. You have been the beneficiary's physician for the past several years. The service you furnish relating to the patient's hypertension involves an expanded problem-focused history, an expanded problem-focused examination and medical decision-making of low complexity. This medically necessary service permits you to bill a mid-level established patient office visit, CPT 99213.

You will report this code along with the established patient preventive medicine service code for a patient 65 years and older, CPT 99397. Medicare's average allowable for CPT 99213 is $47.23 (your payment may vary, depending on your geographic location). Assuming you submit an assigned claim and the beneficiary has met his deductible, your carrier will pay you $37.78, or 80% of the allowable. Your established charge for a comprehensive preventive examination is $150, so you would bill the beneficiary $102.77, or $150 minus $47.23.

You would report the International Classification of Diseases (ICD-9) code for benign hypertension, 401.1, to justify the 99213. You would likely report ICD-9 code V70, general medical examination, as the reason for the 99397, even though Medicare will never pay for the preventive medicine service code regardless of the diagnosis.

Ask your carrier about its policy on how to bill when you provide a Medicare covered, medically necessary service during the course of a comprehensive preventive examination. The formula your carrier uses to determine how much to bill the patient may differ slightly from what is described above.

You should explain to your patients that they will be billed for the preventive examination, the portion not covered by Medicare. This will be especially helpful if you have not billed a medically necessary service in conjunction with a preventive service in the past.

Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, call him at 202-261-4533, send a fax to 202-835-0441 or send an e-mail to bbaker@acponline.org.

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