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)


EPSDT CPT codes well-child visits STAGE (Age) NEW PATIENT CPT CODE

ESTABLISHED PATIENT CPT CODE

INFANCY (Prenatal – 9 months) 99381 99391
EARLY CHILDHOOD (12 months – 4 years) 99382 99392
MIDDLE CHILDHOOD (5 years – 10 years) 99383 99393
ADOLESCENCE STAGE 1 (11 years – 17 years) 99384 99394
ADOLESCENCE STAGE 2 (18 years – 21 years) 99385 99395
EPSDT CPT codes for sensory screening
SERVICE CPT CODE
VISION 99173
HEARING (Audio) 92551
HEARING (Pure tone-air only) 92552
Adult annual preventive care visits

New patient

CPT Code 99385: Initial Preventive Medicine New Patient age 18-39 years
CPT Code 99386: Initial Preventive Medicine New Patient age 40-64 years
CPT Code 99387: Initial Preventive Medicine New Patient age 65 years & older

Established patient

CPT Code 99395: Periodic Preventive Medicine Established Patient 18-39 years
CPT Code 99396: Periodic Preventive Medicine Established Patient 40-64 years
CPT Code 99397: Periodic Preventive Medicine Established Patient 65 years & older
Adolescent annual preventive care visits

New patient

CPT Code 99382: Initial Preventive Medicine New Patient age 1-4 years
CPT Code 99383: Initial Preventive Medicine New Patient age 5-11 years
CPT Code 99384: Initial Preventive Medicine New Patient age 12-17 years

Established patient

CPT Code 99392: Periodic Preventive Medicine Established Patient age 1-4 years
CPT Code 99393: Periodic Preventive Medicine Established Patient age 5-11 years
CPT Code 99394: Periodic Preventive Medicine Established Patient age 12-17 years


EPSDT codes PLUS Evaluation and Management (E&M) codes PLUS Modifier 25* PLUS

ICD-9 Diagnosis codes 99381–99385 or 99391-99395 The components of the EPSDT visit must be provided and documented. 99203–99215 The presenting problem must be of moderate to high severity. Documentation must support the use of modifier 25.  V20.2 or V70.0 must be the primary diagnosis diagnosis code for the visit. Add the diagnosis codes for the presenting problem focused evaluation

*If a patient is evaluated and treated for a problem during the same visit as an EPSDT exam, the problem-oriented exam can be billed along with the EPSDT visit when accompanied by the 25 modifier. Modifier 25 means that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day of the procedure or other service which was provided. In other words, two services were provided on the same day by the same provider, which could have been billed separately if the patient had been seen on two separate dates


Limitations for added procedure code: Procedure codes 96160 and 96161 replace discontinued procedure code 99420 and may be reimbursed for services rendered to clients who are 12 through 18 years of age as follows:

• To NP, CNS, PA, physician, and FQHC providers for services rendered in the office setting. Procedure codes 96160 and 96161 will be denied if billed with the same date of service as procedure codes 99384, 99385, 99394, and 99395.

Providers must use procedure code 96160 or 96161 for the required mental health screening. Procedure codes 96160 and 96161 must be billed with the appropriate medical check-up procedure code. Only one procedure code (96160 or 96161) may be reimbursed once per lifetime.

Limitations for added procedure code: Discontinued procedure code 99420 has been replaced by added procedure codes 96160 and 96161. Procedure codes 96160 and 96161 may be reimbursed as follows:

• For services rendered to clients who are 12 through 18 years of age.

• To Federally Qualified Health Center (FQHC) and THSteps providers for THSteps services rendered in the office setting.

Mental health screening for behavioral, social, and emotional development is required at each THSteps checkup. Mental health screening using one of the validated, standardized mental health screening tools recognized by THSteps is required once for all clients who are 12 through 18 years of age.

A mental health screening must be submitted with procedure code 96160 for a screening tool completed by the adolescent, or procedure code 96161 for a screening tool completed by the parent or caregiver on behalf of the adolescent. When claims with procedure code 96160 or 96161 are submitted for mental health screenings, one of the validated, standardized mental health screening tools recognized by THSteps must be used.

Only one procedure code (96160 or 96161) may be reimbursed for the mental health screening per client per lifetime based on the description of the procedure code and the service rendered. Procedure codes 96160 and 96161 will not be reimbursed for the same client for any date of service. Procedure code 96160 or 96161 must be submitted with the same date of service by the same provider as procedure code 99384, 99385, 99394, or 99395. The client’s medical record must include documentation identifying the tool that was used, the screening results, and any referrals that are made.

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