# Medicare Carve Outs and Pricing



## dcarr (Jul 24, 2008)

Looking for some clarification. Our MAC WPS states the beneficiary can only be billed for the difference between the standard fee for the preventive visit (ex: 99397) and the amount that Medicare will cover for the carve outs (G0101, Q0091) which I'm understanding to mean the Medicare allowable, not the standard fee charged. I have seen just the opposite being practiced meaning standard charge for the carve outs subtracted from standard charge for the preventive visit. Using the allowable would leave the patient owing a much larger amount. Could someone please clarify on this subject?


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## Lisa Bledsoe (Jul 24, 2008)

You need to subtract the allowable for Q0091 and G0101 from your office charge for 99397.  Example:
99397            $200.00
Q0091               43.99
G0101               38.13
patient resp    $117.88  for 99397

Hope that helps...


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## RebeccaWoodward* (Jul 24, 2008)

Does this help?

What is the appropriate way to bill for a physician's services with a routine
physical/visit in conjunction with a medically necessary visit (i.e. follow-up visit to monitor use of medications for chronic illnesses)? What is the appropriate way to determine the amount to charge the beneficiary for the non-covered portion of a preventive visit with a covered medical visit: (1) should our established charge for the covered medical visit be subtracted from our established charge for the preventive visit; or (2) the Medicare allowed amount for the covered medical visit?

If the physician performs the preventive/annual exam etc., and also performs a medically necessary E/M service at the same encounter, the physician would report the medically necessary E/M (e.g., 99213) and Medicare will pay for that service. The physician, in turn, is supposed to subtract the 99213 visit payment (*Medicare Allowed Amount*) from their preventive medicine charge. We call this a "carve out." Medicare allows carve outs to give providers an incentive to address both the preventive and covered issues in one visit. Medicare understands that there is a need to address a patient's other concerns related to chronic illnesses during a preventive visit. Allowing carve outs reimburses the physician for those components performed in a preventive visit that would normally be covered by Medicare if done independent of that visit, while still allowing the physician to be compensated for the remaining preventive services at their normal standard fee.
In addition, this benefits the beneficiary as some of their expenses for that visit were covered and they need only come in once. 
**Due to the number of questions we receive regarding the amount to charge for carve out
services, WPS staff sought and received clarification from CMS:
• First, select the most appropriate code for the preventative (routine/physical visit) visit
(codes 99381-99387 or 99391-99397).
• Next, select the most appropriate Evaluation and Management (E/M) code for the
medically necessary portion of the visit.
• Subtract the appropriate Medicare Allowed Amount for the medically necessary E/M visit
from your charge for the preventive exam.
• The remaining balance is what you will charge for this portion of the exam. This portion
will be a "non-covered" service.


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## dcarr (Jul 24, 2008)

I was looking for reassurance and an easy way to train employees regarding this. Should the 99397 be submitted to Medicare as $200 or $117.88 with the QY modifier? I'm trying to envision the entire billing process to ensure that the account will show the correct patient balance after Medicare pays.


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## Lisa Bledsoe (Jul 24, 2008)

dcarr said:


> I was looking for reassurance and an easy way to train employees regarding this. Should the 99397 be submitted to Medicare as $200 or $117.88 with the QY modifier? I'm trying to envision the entire billing process to ensure that the account will show the correct patient balance after Medicare pays.



99397 would go to Medicare as $117.88 (I think you meant GY not QY).


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## dcarr (Jul 24, 2008)

Yes, sorry, a typo. Thank you for all your help in this matter!


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## codecrazy (Mar 24, 2010)

*where?*

Where do I find this info on the CMS site or Medlearn site.  Thanks for your help.


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## RebeccaWoodward* (Mar 24, 2010)

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

30.6.2

When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381-99397), consider the covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physician's current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician's actual charge for the visit.


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## RebeccaWoodward* (Mar 24, 2010)

This link is a little more user friendly...

http://www.medicarenhic.com/providers/pubs/Preventive Services Billing Guide.pdf

Page 36


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## codecrazy (Mar 31, 2010)

*First Coast*

I'm under FSCO and they do not have anything on website.  So I called and they had to keep putting me on hold to ask someone else, when she came back she still had no idea were I could get information on FSCO instructionsor education.  If anyone has a web address for it please let me know as my
doctors like me to use the information from them.


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