Preventive Medicine Services for Medicare Patients

April 10th, 2009 - Codapedia Editor

Categories: Claims Coding Medicare Preventive Medicine Service

The most widely known fact about Medicare and preventive medicine is that fee-for-service Medicare does not cover an annual physical exam. This is because in its beginning, Medicare was prohibited from paying for routine services. Over the years, Congress has mandated the payment of some screening and other wellness related services for Medicare patients. The resources tab has the Quick Reference Guide to covered preventive services for Medicare, and the citations guide a link to the CMS manual system for more details.

Medicare covers one Initial Preventive Physical Exam (the Welcome to Medicare visit--see the article about this service in Codapedia.) This service is paid once in the beneficiary's lifetime. Beginning Jan 1 2009, the patient is eligible within the first 12 months of service. It is not your typical physical exam, but has specific history and screening components. It requires giving the patient a written plan that describes the covered services for which they are eligible.

Women patients are eligible for a screening pelvic and clinical breast exam (G0101) every two years for low risk patients and every year for high risk patients. That service must include the breast exam, and at least 7 of the 11 exam elements described in the service. There is a Codapedia entry on this service, as well.

Many of the preventive medicine services on the chart must be submitted with the covered diagnosis code for screening (often a V code) and have strict frequency limits. The chart lists lab, procedures and services covered by Medicare.

What about an office visit for a problem that is addressed on the same day as a routine service?

Example: patient presents for annual physical exam but reports a significant exacerbation of diabetes, requiring change in medicine, additional diagnostic lab work and instructions from the physician to return to the office in one week.

Physician office:

Bill for 99397            $180
Bill to Medicare 99213        75.

Patient due bill:           105
Patient also responsible for 20% of allowed amount of 99213

If G0101 (pelvic and clinical breast exam) or Q0091 (obtaining screening pap) reported on same day, subtract their fees in the same manner as office visit in example above.

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