Medicare Requisites for Reporting And Reimbursing Preventive Services

Medicare Rules for Reporting And Reimbursing Preventive Services


Preventive services, with respect to providing well woman care are periodic, preventive medicine visit that include and require documentation of a comprehensive history, a comprehensive physical exam, counseling anticipatory guidance and risk factor reduction and any appropriate diagnostic procedures or lab test. They are based on the woman’s age. And you must select whether this is a new or established patient.

And again, the same guidelines apply for that new and/or established patient in that if a woman has received billable service by another provider or yourself of the same specialty in the last three years, she's considered an established patient.

 CMS, the Center for Medicare and Medicaid Services evaluation and management documentation guidelines don’t apply to preventive codes. Medicare and other payers have different rules for reporting and reimbursing preventive services. So if we're billing a Medicare patient, it's a little bit different than billing the non-Medicare patient for preventive services. Medicare does not cover some screening services that are commonly provided during preventive visit.

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In the CPT code book, we will find the preventive medicine codes, the 99381 to 99387 would be used for new patient codes. And the 99391 to 99397 are the established patient, preventative visits for a well woman that see.

And then the typical diagnosis code that is matched with the well women annual is the V72.31 which is the well women gynecological exam. And so, typically this would be a code that would be matched with the preventive medicine to tell the payer that this is in fact a well woman annual examination.

 Medicare annuals however use a diagnosis code of V76.2. And by the way, V codes are section of the ICD9 code books that list diagnoses that are problems. Those are a well women or maybe at risk for or family history of. So the V denotes that this is essentially a healthy person maybe someone with risk factors or personal or family history of a problem but don’t currently present with a problem.

Medicare will pay for a screening path and pelvic exam which includes a clinical breast exam every two years. So for the past eight years, Medicare has approved this visit every couple of years.

Now, Medicare will cover a routine well woman exam. That's the head to toe comprehensive physical exam that most of us that provide women’s health do on an annual basis.

So the amount reimbursed by Medicare for the coverage screening services which would be pelvic and breast exam every couple of years or annually if the patient is high risk and is deducted from the amount billed to the patient for other preventive services.

So it's important when a Medicare patient presents a well woman care that you have her signed an advanced beneficiary notice. And ABN will tell the patient that Medicare pays for the screen exam every two years. And if you're presenting today for a head to toe well woman exam, either your supplemental insurance provider or you yourself will be billed for services after we carve out what is covered by the Medicare program.

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