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Tip: Medicare's pointers for billing preventive and problem visits

Compliance Monitor, August 4, 2004

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Medicare considers a covered physician service provided at the same place and on the same date of service as a preventive-medicine service (CPT codes 99381-99397) as being provided instead of part of the preventive medicine service.

Although Medicare doesn't cover preventive-medicine services, physicians may charge beneficiaries for the noncovered remainder of the service, which is the difference between the charge for the preventive service and the charge for the covered visit. Medicare pays the lesser of the fee-schedule amount and the physician's actual charge for the covered visit.

Physicians may perform covered and noncovered tests during the same encounter (e.g., screening x-ray, EKG, lab tests). Medicare will only pay for procedures ordered to diagnose or monitor a symptom, medical condition, or treatment if the service is covered and medically necessary.

Physicians don't have to give beneficiaries written notice of noncoverage for preventive services. However, the physician must notify the patient of his or her liability to pay for services that are not medically necessary to treat the illness or injury.

Source: Adapted from the Medicare Carrier's Manual.

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