Corporate Compliance

Note from the Instructor: More on Medicare Preventive Services

Medicare Insider, June 30, 2015

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This week’s note from the instructor is written by Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist for HCPro.  
A few weeks ago, I wrote an article about billing for preventive services in a rural health clinic (RHC). Since then I have received several questions about preventive services, specifically the Initial Physical Preventive Exam (IPPE) and the Annual Wellness Visit (AWV), which are performed in hospital outpatient departments, provider-based clinics/departments, and freestanding physicians’ offices.
Medicare differentiates between these exams based on eligibility, timing, and the purpose of the visit:
  • The IPPE is an introduction to Medicare and covered benefits, with a focus on health promotion and disease detection. It must be performed within the first 12 months after the effective date of the beneficiary’s Medicare Part B coverage.
  • The AWV is intended for reviewing the patient’s history, risk factors for diseases, and medications. It is also intended to provide personalized health counseling and establish or update a written personalized prevention plan.
Although there are very specific HCPCS codes used to bill for the IPPE (G0402) and the AWV (G0438 initial and G0439 subsequent), Medicare does not require a specific diagnosis code for coverage of these services. The HCPCS code and the frequency in which the services are provided drive the coverage rules.
Hospitals may encounter difficulties with billing and payment when other diagnostic services are ordered in connection with the IPPE or AWV. For example, it is not uncommon for a physician to order laboratory services following these exams and give an ICD-9 diagnosis code in the range of V70.0–V70.9 (general health examination) as the reason for the test. However, the Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report, Clinical Diagnostic Laboratory Services (otherwise known as the Lab NCD Manual) lists these diagnosis codes as never covered. If a code from the non-covered section of the manual is provided, the provider may bill the test to the Medicare beneficiary without issuing a mandatory ABN. By reporting the non-covered diagnosis code, it would appear to Medicare that the test was performed for screening rather than diagnostic purposes. Instead, the practitioner or the provider may issue a voluntary ABN to inform the patient of his or her financial liability in the case of a never covered item or service.
Unfortunately, the patients and sometimes the practitioners are under the assumption that the lab services are also covered as part of the IPPE or AWV. While there are several other laboratory preventive services that are covered by Medicare, they also have specific HCPCS codes and frequency limitations and many have specific diagnosis code requirements as well. A list of these tests can be found in the links that follow.
Practitioners who order additional services and the providers who may perform them must be aware of the coverage and billing differences between diagnostic and screening services that may result as a follow up to one of the covered preventive exams. Not only will the provider’s bottom line be affected by incorrectly billing for additional services without a covered diagnosis, but the patient’s out-of-pocket expense will potentially increase.
The following resources provide complete coverage and billing guidance for Medicare preventive services when provided in any setting.

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