Preventive Healthcare for Medicare Enrollees: A CMS Guide

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Preventive Services PRESENTED BY JAN
RASMUSSEN, PCS, ACS-OB, ACS-GI PROFESSIONAL
CODING SOLUTIONS
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PREVENTIVE OFFICE VISITS 99381-99397
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Diagnosis Coding

• Z00.00 Encounter for general adult medical
  examination without abnormal findings
• Z00.01 Encounter for general adult medical
  examination with abnormal findings

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Prevent Covered Visit Same Day

• IOM 100-04 C12 30.6.2
• When a physician furnishes a Medicare
  beneficiary a covered visit, at the same place
  and on the same occasion as a preventive medicine
  service (CPT codes 99385-99387 or 99395-99397),
  consider the covered visit to be provided in lieu
  of a part of the preventive medicine service of
  equal value to the visit.
• The physician may charge the beneficiary, the
  amount by which the physicians current
  established charge for the preventive medicine
  service exceeds his/her current established
  charge for the covered visit.

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Breast and Pelvic Exam (G0101)

• Payable every 2 years for Medicare patient.
• If considered high risk payable annually.
• High risk identified with Z91.89 as primary
  diagnosis
• sexual activity under 16 yrs old (Z72.51, Z72.52,
  Z72.53)
• 5 sexual partners (Z72.51, Z72.52, Z72.53)
• hx of sexually transmitted dx (Z87.42)
• absence of 3 negative paps (R87.619)
• hx of HIV (Z21 or B20)
• no pap smears for 7 years (no ICD-10)
• prenatal exposure to DES (P04.89)

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G0101

• Reimbursement less than 99212
• Deductible does not apply.
• Can be billed with another E/M sick visit.
• Requires carve-out when billed with preventive
  med code (99385-99387or 99395-99397).
• Routine
• Z01.411, Z01.419
• Should only be used when the provider performs a
  full gynecological examination.
• Z12.4 for special screening, malignant neoplasm
  cervix.
• Patients without uterus or cervix use
• Z12.72 screening for malignancy of vagina
• Hysterectomy for non malignant condition
• Z12.79 screening for malignant neoplasm of other
  genitourinary organs
• No longer screening
• Follow up for completed treatment for malignant
  neoplasm (Z08) with Z90.710/Z90.711 acquired
  absence of cervix/uterus or just uterus and PH
  Z85,41, Z85.42, Z85.43 hysterectomy for
  malignancy

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Q0091

• Q0091 billed separately for collection of pap
  smear with same diagnosis as G0101
• Note MUST state pap smear obtained!
• Screening pap smears also payable every 2 years.
• Q0091 and G0101 may not always coincide for
  frequency (i.e. 2002 Q0091 and 2003 G0101).
• Requires waiver if performed more frequently.

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S Codes

• Well Service Codes Non Medicare
• S0610 Annual gynecological examination, new
  patient
• S0612 Annual gynecological examination,
  established patient
• S0622 Physical exam for college, new or
  established patient

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RISK AREAS PREVENT MED

• 99204/05 or 99214/15 instead of prevent medicine
  code.
• Medicare considers that fraudulent billing
• Combined prevent medicine and f/u chronic
  problems.
• Here for annual evaluation of HTN,
  hypothyroidism and hyperlipidemia and preventive
  medicine services.
• No clear documentation of separate work only
  renewed meds
• Sick services being provided for nothing.
• Never reporting prevent med services, G0101,
  Q0091.
• Incomplete documentation to support sick visit.
  
• Complaints not addressed in AP

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IPPE

• Effective 1/1/05
• Should be called Welcome to Medicare Evaluation
  rather than exam
• G0402 - Initial preventive physical examination
• 1 initial preventive exam within first 12 months
  after the effective date of beneficiary's first
  Part B coverage period

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Annual Wellness Visit (AWV)

• Preventive wellness visit not a routine physical
  check up as patients are accustomed to
• AWV does not replace a complete head-to-toe
  physical exam.
• A yearly physical CPT codes 99385-99387,
  99395-99397) is never a covered service
• G0438 initial
• G0439 subsequent
• No deductible or coinsurance

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Hepatitis C Screening G0472

• High risk individuals
• Current or past history of illicit injection drug
  use and persons who have a history of receiving
  a blood transfusion prior to 1992.
• Covered annually only for persons who have
  continued illicit injection drug use since the
  prior negative screening test.
• Non high risk
• Born from 1945 through 1965.

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99406/99407 Smoking Cessation

• 99406 Smoking and tobacco use cessation
  counseling visit intermediate, greater than 3
  minutes up to 10 minutes
• Reimbursement approximately 15.00
• 99407 Smoking and tobacco use cessation
  counseling visit intensive, greater than 10
  minutes
• Reimbursement approximately 28.00

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G0442/G0443 Alcohol Misuse

• G0442 Annual alcohol misuse screening, 15 minutes
• ICD-10 Z13.89 unless alcohol misuse identified
• Only once in 12 month period
• G0443 Brief face-to-face behavioral counseling
  for alcohol misuse, 15 minutes
• ICD-10 F10.xx codes

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G0444 Depression Screening

• G0444 Annual depression screening, 15 minutes
• Cannot be paid performed more than one time in a
  12-month period
• Not for patients with confirmed depression
  diagnosis
• ACA indicates Do not provide long-term pain
  management without a psychosocial screening or
  assessment.
• High probability that any person with a chronic
  pain syndrome has a concomitant psychological
  disorder, most notably depression and/or anxiety.
• Diagnosis (unless depression detected) Z13.89

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G0445 STI Prevention

• G0445 Semiannual high intensity behavioral
  counseling to prevent STIs, individual,
  face-to-face, includes education skills training
  guidance on how to change sexual behavior
• Provided by a Medicare eligible primary care
  provider in a primary care setting
• Covers up to two individual 20- to 30-minute,
  face-to-face counseling sessions annually for
• All sexually active adolescents and for adults at
  increased risk for STIs

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Counseling for Obesity

• G0447 Face-to-face behavioral counseling for
  obesity, 15 minutes
• For prevention or early detection of illness or
  disability.
• Obesity defined as BMI 30 kg/m2,

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Immunizations

• Pneumococcal, influenza, COVID 19 and hepatitis B
  vaccine and their administration
• Hepatitis B must be considered high risk
• Shingles vaccination under Part D

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Tracking Eligibility

• Through CMS HIPAA Eligibility Transaction System
  (HETS) either directly or through your
  eligibility services vendor
• Through your MAC provider call center Interactive
  Voice Response (IVR) unit,
• OR
• Through your MAC provider web portal.

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