# Medicare Annual Physicals



## KristieStokesCPC (Jul 29, 2008)

I am still having the worst time with Medicare to get a physical paid for. I know they will absolutely not pay for diagnosis code V70.0 (annual exam). I have copied his note below for help. I'm not sure that I can use V15.89 to get it paid...  

CC: 
Mr. XX is a 69-year-old male.  He is here for an annual exam.  

HPI: 

Patient complains of annual exam.  His last physical exam was 4 years ago.  He underwent colonoscopy 1979 years ago with normal results.   He's had vision screening done 10 years ago and this was normal.  
Smoking Status:  Nonsmoker 

ROS: 
CONSTITUTIONAL:  Negative for chills, fatigue, fever, and weight change.  
EYES:  Negative for blurred vision, eye pain, and photophobia.  
E/N/T:  Negative for hearing problems, E/N/T pain, congestion, rhinorrhea, epistaxis, hoarseness, and dental problems.  
CARDIOVASCULAR:  Negative for chest pain, palpitations, tachycardia, orthopnea, and edema.  
RESPIRATORY:  Negative for cough, dyspnea, and hemoptysis.  
GASTROINTESTINAL:  Negative for abdominal pain, heartburn, constipation, diarrhea, and stool changes.  
MUSCULOSKELETAL:  Negative for arthralgias, back pain, and myalgias.  
NEUROLOGICAL:  Negative for dizziness, headaches, paresthesias, and weakness.  
HEMATOLOGIC/LYMPHATIC:  Negative for easy bruising, bleeding, and lymphadenopathy.  
ENDOCRINE:  Negative for hair loss, heat/cold intolerance, polydipsia, and polyphagia.  
PSYCHIATRIC:  Negative for anxiety, depression, and sleep disturbances.  

Immunizations: 
None

Allergies: 
  No Known Drug Allergies. 

Current Medications: 
Valtrex 500mg Tablet take one tablet qd 

OBJECTIVE:

Vitals: 

Current: 2/26/2008 8:56:21 AM
Ht: 67 inches;  Wt: 195 lbs;  BMI: 30.54
T: 98 F (oral);  BP: 138/77 mm Hg (left arm, sitting);  P: 92 bpm (left arm (BP Cuff), sitting);  R: 16 bpm
VA: 20/50 OD, 20/25 OS (without correction)

Exams: 

GENERAL: well developed, well nourished, in no apparent distress 
EYES: lids and conjunctiva are normal; PERRLA; EOMI;  fundoscopic exam reveals bilateral loss of red reflex, left > right; 
E/N/T: normal external ears and nose;;  Ears: left TM is normal;  left EAC is normal; right EAC is occluded by cerumen;  Hearing Screen: Able to hear fingers rubbed together with both ears;  Nose:  normal nasal mucosa, septum, turbinates, and sinuses; Lips/Teeth/Gums: gingival edema; white ulcer right lower outer gum with dental caries right posterior molar into gum line Oropharynx:  normal mucosa, palate, and posterior pharynx; 
NECK: Neck is supple with full range of motion; thyroid is normal to palpation; 
RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs; 
CARDIOVASCULAR: normal rate; regular rhythm; no murmurs carotids: 2+ amplitude, no bruits; 2+ pedal pulses; no edema; 
GASTROINTESTINAL: normal bowel sounds; no masses or tenderness; no organomegaly rectal exam: normal tone; nontender, guaiac negative stool; guaiac negative stool; 
GENITOURINARY: prostate: no nodules, tenderness, or enlargement; 
LYMPHATIC: no enlargement of cervical nodes; right submandibular node; 
MUSCULOSKELETAL: digits/nails: no clubbing, cyanosis, or evidence of ischemia or infection;  normal gait; grossly normal tone and muscle strength; full, painless range of motion of all major muscle groups and joints no masses, effusions, misalignment, crepitus, or tenderness in major joints; 
NEUROLOGIC: cranial nerves: 2-12 grossly intact;  normal DTR's elicited in biceps, triceps, supinator, knee, and ankle jerk; sensation: subjectively intact to light touch; 
PSYCHIATRIC: mental status: alert and oriented x 3; appropriate affect and demeanor; 

Lab/Test Results: 

LABORATORY RESULTS: 
Urinalysis: (-) glucose,  (-) bilirubin,  (-) ketones, S.G. 1.020,  trace blood, pH 6.5,  (-) protein,  normal (0.2-1 EU) urobilinogen,  (-) nitrite,  (-) leukocyte esterase; Hemocult: negative; 

Procedures: 
Annual exam 

VISUAL ACUITY: 
OS: 20/25 (uncorrected); 
OD: 20/50 (uncorrected); 

Cerumen impaction 

Procedure: Cerumen impaction is noted in the right ear.  The degree of wax accumulation is moderate in the right ear.  With minimal difficulty, using a syringe irrigation, the wax is removed.  Removed from ear was hard balls of wax.  The patient tolerated the procedure well.  
There were no complications.  


ASSESSMENT: 

V70.0	    Annual exam 
521.07	    Dental caries of smooth surface 
366.9	    Cataract 
380.4	    Cerumen impaction 

PLAN: 

 Annual exam 
LABORATORY:  Labs ordered to be performed today include, CBC, lipid panel, comprehensive metabolic panel, PSA, TSH, and urinalysis.  
REFERRALS:  Outside referral to a gastroenterologist ( to perform screening colonoscopy ).  

  Orders: 
     Collection of venous blood by venipuncture  
     Complete (CBC), automated (Hgb, Hct, RBC, WBC, and platelet count) and automated differential WBC co  
     Lipid panel (total cholesterol, HDL, triglycerides)  
     Comprehensive metabolic panel (Albumin, Bilirubin, Ca, CO2, Cl, Creatinine, Glu, alkaline phosphatas  
     PSA  
     Thyroid stimulating hormone (TSH)  
     Urinalysis, automated, without microscopy  
     Referral  
     Screening visual acuity, quantitative, bilateral  

 Dental caries of smooth surface 

  Prescriptions: 
  Penicillin VK 500mg Tablet Take 1 tablet(s) by mouth bid for 10 days  #20 (Twenty) tablet(s) Refills: 0 

  Orders: Patient advised to schedule dental appointment ASAP, and agrees to comply. 

 Cataract 

  Orders: Patient advised to schedule optical evaluation, agrees to comply. 

 Cerumen impaction 

  Orders: 
     Removal impacted cerumen, one or both ears  


Other Orders: 
     Blood occult, perioxidase activity, qualitative; feces for colorectal neoplasm screening  

CHARGE CAPTURE: 

Primary Diagnosis: 
V70.0	    Annual exam 

                   Orders:
                    99387  Preventive medicine, new patient, age 65+ years  
                    36415  Collection of venous blood by venipuncture  
                    81003  Urinalysis, automated, without microscopy  
                    REF  Referral  
                    99173  Screening visual acuity, quantitative, bilateral  

521.07	    Dental caries of smooth surface 

                   Orders:
                    99202-25  Office/outpatient visit; new patient, level 2  

366.9	    Cataract 

380.4	    Cerumen impaction 

                   Orders:
                    69210  Removal impacted cerumen, one or both ears  


Other Orders: 
                    82270  Blood occult, perioxidase activity, qualitative; feces for colorectal neoplasm screening  



Thanks
Kristie Stokes, CPC-A


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## johnstond (Jul 29, 2008)

*Debbie-CPC*

Is your claim being denied for the dx or the CPT?  We bill "welcome to Medicare" physicals with HCPCS  code G0344 and use dx V70.0 and get paid.


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## meenal (Jul 29, 2008)

I agree with you. I think that the CPT is the reason for denial and not the Dx on the above scenario.


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## KristieStokesCPC (Jul 29, 2008)

It's not a Welcome visit - it's just a routine visit and we do not have an ABN signed by him. We will most likely have to eat the bill but I want to make sure all avenues are tried to get it paid first. 

Thanks
Kristie


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## Herbie Lorona (Jul 29, 2008)

Medicare does not pay for preventative exams 9938* - 9939*. Or they don't pay for a sick visit 9920* - 9921* with the V70.0 diagnosis


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## KristieStokesCPC (Jul 29, 2008)

I know they won't pay for those codes, I just didn't know if anyone else has ever faced this problem and if there was a way to file and get paid. So the reality is that I will pretty much be eating the bill?  

Thank you all


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## Lisa Bledsoe (Jul 29, 2008)

You do not need to eat the bill...since it is an exclusion from Medicare benefits, you don't have to get an ABN and you can bill the patient.  Although, it's nice to get the ABN so the patient knows what's coming.  Not a requirement.


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## dmaec (Jul 29, 2008)

Hey Kristie, I see a few things in the note:  We all know Medicare doesn't pay for preventive visits - but you need a .GY modifier on the "new" preventive code - I've never coded an eye exam 99173 separate with a px for MC - you can't have two  "new" patient codes for this person so the E/M needs to be an established patient (is that not being paid also, maybe that's why)- I'd go with still a level 2 (99212.25) though because I don't think they really did all that much to support a higher code but I haven't taken the time to score this note out.  (you might want to do that first to be sure of it's level, but it has to be est patient). 
I don't see where cerumen removal was done "per the guidelines" - so it appears to me to be ear irrigation only which is included in the E/M - dx 380.4 (no 69210)
sadly, I don't see any covered dx's for all those labs! (ewwww). Without an ABN for the labs, you will have to write them off.  The PSA should be the G-code CPT and screening dx- appears you'll need to use screening dx's for the other labs too -  
However, Lisa is correct - you don't eat the cost of the preventive service, it shouldn't get written off because it's never covered by Medicare (excluding the welcome to MC px's) and the patients are aware of that. It doesn't require an ABN to be signed.
I'm not sure what you wanted to attach the V15.89 code to?...  what's the other specified personal history presenting hazards to health?


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## mkj2486 (Aug 5, 2008)

When we bill a medicare patient for a prevent/annual exam and a problem visit, we deduct the cost of the problem visit from the prevent and only bill the patient for the remainder.  It just makes it easier for the patient to swallow.  This is a policy our facility has.  So if the is $140 and the problem visit is $35 the patient would only pay $105.  Also, in our policies if we are billing a prevent and a problem visit for the same day/time, we use the new patient codes for each.  (GY modifier on the prevent) We do not have a problem in getting the problem visit paid by Medicare.


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## mraymond74 (Aug 6, 2008)

*Michelle R, CPC*

I will completely agree with Donna & with the post above mine.
Were I work we would charge the 99397 with modifier GY, and office visit with modifer 25 attached.  However, I took a medicare class a year or so ago.  
Per Medicare guidlines MCM15501E - When a physician furnishes a Medicare beneficiary a covered vist, at the same place and on the same occasion as a preventative medicine service,consider the covered visit to be provided in lieu of the part preventative medicine service of equal value to the visit.
Basically what this means is: The physcian may charge the medicare patient, the amount by which the physician's current established charge for the preventative medicine service exceeds his/hers current established charge for the covered visit.

I hope this helps!

Michelle R


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## KristieStokesCPC (Aug 19, 2008)

Thank you all for your help... things are clearer now  Ya'll are great!


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## wlacey (Oct 10, 2008)

*Physical exams Medicare*

We bill a preventative exam with an e/m service and reduce the approved amount of the e/m from the preventative exam.  I have found that for new patients the documentation does not always support two services. I think that is the key. What idoes the documentation show.  A level 99203 and 99204 requires the same or more work then some of our physical forms so why would we code both? That would be double dipping. It is case by case and educating the providers is the key. It would make more sense to code 99212 or 99213 which requires less. Coding two new patient services would be incorrect I agree.
Wendy RHIT,CCS-P, CPC


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