CPT 99393, 99394, 99395, 99396 - 99397 - screen services - Does Medicare cover ?

99393 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years)

99394 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)

99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years

99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years

99397 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older

Medicare Screening Services

Physicians are often confused about how to document and report preventive services provided to their Medicare patients. This document is designed to assist physicians in documenting, reporting and receiving reimbursement for these services.

Medicare does not cover comprehensive preventive visits (99381-99397). However, Medicare does cover certain screening services which are often performed during preventive visits such as:

• Screening pelvic exam
• Collection of screening Pap smear specimen
• Interpretation of the Pap smear test (reported by the laboratory)
• Screening hemoccult
• Screening mammography
• Screening bone mass measurement
• Initial preventive physical examination (Welcome to Medicare examination)
• Diabetes screening
• Cardiovascular blood test
• Tobacco use cessation counseling

The table at the end of this document provides an overview of Medicare screening services. The Centers for Medicare and Medicaid (CMS) have published several educational products that describe covered screening services available to Medicare patients.


OVERVIEW

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse the Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

When a Preventive Medicine service and Other E/M services are provided during the same visit, only the Preventive Medicine service will be reimbursed.

Screening services include cervical cancer screening; pelvic and breast examination; prostate cancer screening/digital rectal examination; and obtaining, preparing and conveyance of a Papanicolaou smear to the laboratory. These Screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine service rendered on the same day.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes.

Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes.

Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes.

Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.









Preventive Medicine Visits

• Not all insurers pay for preventive medicine visits. For example, these visits are not covered by Medicare. If you suspect a patient does not have coverage, advise him or her of your billing policies.

• Insurers that do cover preventive medicine visits (eg, many HMOs) generally reimburse them at relatively high rates.

• Regardless of whether a preventive medicine visit is covered, the relevant codes can be used alone or in conjunction with a code for an E&M service (see below).


Patient and Visit Preventive Medicine Code New patient, initial visit

Age 40 through 64 years 99386
Age 65 years and older 99387 Established patient, periodic visit Age 40 through 64 years 99396
Age 65 years and older 99397



Coding and Billing

Preventive Medicine Visits in Conjunction with an E&M Service

What should you do when you find a problem during an otherwise preventive medicine visit?

• Select the appropriate preventive medicine code and the E&M code that best represents the problems addressed.

Example CPT Code Charge Preventive medicine visit Established patient, over 65 years old 99397 $225

Office visit, level 4 99214 $175 The patient will owe the difference if he or she has Medicare and a secondary insurance.    5 – $175 = $50 Medicare allowable for a level 4 visit $87.78 Medicare pays 80% $70.22 Patient or secondary insurance pays
remaining 20% $17.56

Patient total out-of-pocket may be up to $50 + $17.56 = $67.50

Note: Medigap will pay the secondary insurance amount but not the additional charge for the preventive medicine service that is not covered.

• Do not increase the level of the code for the E&M service to account for preventive medicine efforts.


Preventive Services Covered Under the Affordable Care Act CPT CODE(S) (Append Modifier 33 to services that are not inherently  reventive to i dicate an ACA service e.g. 99201-99215) HCPCS CODE(S)  (Medicare & some commercial payers) Suggested ICD9 CODE(S) (In order of preference) Note: Most private payers expect that these preventive services (counseling, screening and immunizations) occur during the annual preventive exam and may not reimburse separately for these on the same day nor at subsequent visits.


* CMS billing guidelines indicate Physician or Advanced Practice Practitioners may use modifier 25 with modifier EP or modifier TJ for preventive medicine service codes (99381 - 99397 and additional screening codes 99406-99409 and 99420) when reported in conjunction with immunization administrative services (90460-99474). Physician or Advanced Practice Practitioners may submit corrected replacement claims if appropriate.


* Modifier 25 may be used with other non-preventive medicine E/M services when reported in conjunction with immunization administration when the E/M service is significant and separately identifiable. Exception: If a vaccine is billed with the same date of service as code 99211, NCCI edits do not permit the E/M code to be reimbursed. CMS has stated that an E/M code should not be billed in addition to the administration code(s) when the beneficiary presents for vaccine(s) only.


* CMS billing guidelines indicate Physician or Advanced Practice Practitioners may use modifier 25 with modifier EP or modifier TJ for preventive medicine service codes (99381 - 99397 and additional screening codes 99406-99409 and 99420) when reported in conjunction with immunization administrative services (90460-99474). Physician or Advanced Practice Practitioners may submit corrected replacement claims if appropriate.





99381, 99382, 99383, 99384, 99385, 99386, 99387 (Preventive visits for new patients by age)

G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment)

V70.0 (Routine general exam)

99391, 99392, 99393, 99394, 99395, 99396, 99397(Preventive visits for established patients by age)

G0438 (Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit)

V72.31 (Routine gyn exam)

G0439 (Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit)

S0610 (Annual gynecological examination, new patient)

S0612 (Annual gynecological examination, established patient)

S0613 (Annual gynecological examination; clinical breast examination without pelvic evaluation)




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