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

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Billing for preventive exams, assisted living visits

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

By Brett Baker

Q: How do I select a code when I perform a comprehensive preventive examination?

A: Refer to Current Procedural Terminology (CPT) 2000 to select new or established preventive medicine service codes. Preventive medicine service codes range from CPT 99381-99387 for new patients and from CPT 99391-99397 for established patients.

Select the code that corresponds to the age of the patient. For example, with patients who are 65 or older, report CPT 99387 for a new patient and CPT 99397 for an established patient.

Q: Can I bill a new patient preventive medicine service code the first time I perform a comprehensive preventive examination, even if I have been the patient's regular physician?

A: No. You should bill for the comprehensive preventive examination using the service code for established patient preventive medicine.

The standard for determining whether to bill a new or established patient code applies uniformly to all evaluation and management (E/M) service codes that distinguish between new and established patients. CPT 2000 defines a new patient as "one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years."

New patient preventive medicine E/M codes are typically used to report services provided to a patient who is new to an area and establishing a relationship with a new physician, rather than presenting with an illness.

Q: Does Medicare pay for a comprehensive preventive examination if I bill for it using new or established preventive medicine service codes?

A: The law prohibits Medicare from paying for a comprehensive preventive examination. Medicare beneficiaries must pay for such an exam themselves. The Medicare limiting charge does not apply.

Although you are not required to have beneficiaries sign a waiver acknowledging that the exam is not covered by Medicare, you should make sure they know about their financial responsibility before you perform the exam.

For more on billing for prevention-related care, see "How to bill Medicare for prevention-related care."

Q: How do I code a visit to a patient in an assisted living facility that has a nurse on the premises? It seems that the appropriate code could range from a nursing facility visit to a home visit.

A: You should report the appropriate domiciliary, rest home or custodial care service code (99321-99333). It is appropriate to bill a domiciliary code even though the CPT introductory text to these codes states that they are to be used when "the facility's services do not include a medical component." This stipulation was intended to distinguish the domiciliary codes from the nursing facility codes.

You cannot bill a home visit even if the patient is in his or her own apartment or room in the assisted living facility and is relatively self-sufficient. CPT defines a "home" as a private residence—the sort of dwelling that would not facilitate a physician treating multiple patients in a single trip. Also, you cannot bill a nursing facility visit. The mere presence of a nurse on the premises of an assisted living facility fails to qualify it as a nursing facility.

Q: How much time do I have to file a Medicare claim for services I provide?

A: Typically, you must file a Medicare claim no later than the end of the calendar year following the year in which the service was provided. For example, you have until Dec. 31, 2001 to bill for a service provided on Sept. 15, 2000.

If the service is furnished during the last three months of the calendar year (October-December), you have until Dec. 31 of the second year after the year in which the service was rendered. For example, you have until Dec. 31, 2002, to bill for a service provided on Oct. 23, 2000.

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

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