Internal Medicine Coding Alert

Question: Medicare is denying our claims for routine physical exams of patients who have symptoms and the presence of significant chronic illness. We use a primary diagnosis code of V70.0 (routine general examination at a healthcare facility), and then use the chronic illnesses as the second and third diagnoses. What are we doing wrong?

Indiana Subscriber

Answer: Medicare does not reimburse for routine physical exams, according to Tammy Chidester, CPC, billing supervisor at Upshur Medical Management Services, a multispecialty practice in Buckhannon, W.Va. The Medicare Carriers Manual refers to routine exams as one of several services that are never covered under any circumstances.

There are several things your practice can do, however, to improve its payment situation. If the reason for the patients visit was really to discuss one of the chronic conditions, you should list that as the primary diagnosis code and bill an appropriate level of evaluation and management (E/M) service.

Also, dont forget that some preventative services that may be performed as part of a routine physical exam are separately reimbursable by Medicare. A Pap smear (HCPCS code Q0091, ICD-9 code V76.2) can be billed every three years for patients who are at average risk for cervical cancer and every year for patients at high risk (V15.89). A breast and pelvic exam (G0101, V76.2) can be billed every year.

Finally, you may bill the patient directly for services that will not be covered by Medicare, or you can bill the patients secondary insurance company, if there is one. To bill the secondary payer, you will need to get a denial from Medicare first. You also might want to have the patient sign a waiver that states that the patient understands the services provided may not be covered by Medicare and that the patient will be responsible for payment. With that waiver on file, you can append modifier -GA (waiver of liability statement on file) to the CPT codes for a wellness exam (99381-99397) when the claim is submitted so your local carrier understands that you expect the claim to be denied.