Medicare Compliance & Reimbursement

Find out how to use Medicare’s ‘carve out’ rule.

If providing preventive ob-gyn care for your Medicare patient has you stumped, you’re not alone. Coding and reporting these visits can be confusing — and appending the right modifier is essential.

Context: Suppose a Medicare patient comes into your ob-gyn practice for a preventive service that does not meet the definition or timing requirements of HCPCS code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) as well as an evaluation and management (E/M) service at the same visit. Do you know how to calculate the patient’s fee using the “carve out” rule?

Break down this sometimes puzzling rule into terms you can understand.

Adhere to This Advice for Medicare Carriers

For Medicare beneficiaries, you should take your normal charge amount of the preventive service minus the charge amount for the sick visit. This will give you the total amount you can bill the patient for the preventive part of the visit.

Example: A 66-year-old established patient comes in for her yearly exam. Last year when she presented for her annual exam, you billed the Centers for Medicare & Medicaid Services (CMS) for the breast, pelvic, and Pap, and it was reimbursed. Medicare will pay for these services once every two years.

When the ob-gyn enters the examination room, the patient complains of pain in her left-lower quadrant and black tarry stools for three days. The physician documents an expanded problem-focused history regarding the problem, then completes the annual exam and collects a Pap smear specimen. He orders an abdominal ultrasound and performs an immunoassay test for fecal blood.

First, you would report a well-woman exam (99397, [Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history... established patient; 65 years and older]) with modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non- Medicare insurers, is not a contract benefit) or GX (Notice of liability issued, voluntary under payer policy).

Remember: You should use modifier GX to report that you issued a voluntary advanced beneficiary notice (ABN) for a service that is excluded from Medicare coverage by statute. Modifier GY tells the payer the item or service is:

A) statutorily excluded,

B) does not meet the definition of any Medicare benefit, or

C) not a contract benefit (for non-Medicare insurers).

You’ll report it when the patient does not sign the ABN, which is not required for services Medicare never covers. Modifier GY tells Medicare you know this is not covered, but you need a denial so the patient’s secondary insurance will pay the noncovered portion.

Link this to either Z01.411 (Encounter for gynecological examination [general] [routine] with abnormal findings) or Z01.419 (... without abnormal findings).

Second, according to your ob-gyn’s documentation, you might add 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Link that with R10.32 (Left lower quadrant pain) and K92.1 (Melena).

No double-dipping: You must be vigilant about checking your documentation, as you cannot use any part of the documentation for the preventive exam to determine the level of service for the E/M code.

Tip: Ask yourself, “can I find enough carved-out time or medical decision making [MDM] to support an E/M service that is not part of the preventive care?” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare Solutions in Tinton Falls, New Jersey.

Bottom line: In the above example, the patient’s additional problems and the physician’s additional work present sufficient reason to report the problem-oriented portion of the visit separately.

Here’s How to Calculate Your Fee

Suppose the office fee for 99397 is $200. Your office also normally charges $100 for 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

If you’re billing both a preventive visit and the office visit to Medicare, then you should subtract these amounts. In other words, the amount you can charge the patient for the noncovered portion is $200 - $100 = $100.

Translation: The $100 is what the patient owes for the noncovered service (or the amount you will be submitting to her secondary insurance). Don’t forget: The patient will also be responsible for paying her share of the Medicare allowable and any applied deductible for the problem service.

Watch out: You should not charge $200 for the preventive visit and then also collect reimbursement for the office visit (99213).

Take Covered Annual Exam Into Account

A year in which you can report the Medicare Pap, pelvic, and breast exam requires different calculations.

Example: An established 68-year-old Medicare patient comes in for her annual exam including her Medicare covered Pap, pelvic, and breast exam. Then the ob-gyn managed the patient for urinary stress incontinence at this same visit. You would bill the patient for the noncovered preventive portion of the exam (99397-GY or -GX) and maybe 99213-25 for the office exam, but you will also be billing Medicare for the covered part of the screening exam.

Bill Medicare using G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). Don’t forget modifier GA (Waiver of liability statement issued as required by payer policy) on the G and Q codes when the patient signs an ABN.

Altogether, your claim would look like this:

• 99397-GY or GX (billed to Medicare to get a denial)
• 99213-25
• G0101-GA (ABN signed in case Medicare does not cover this at the time of service)
• Q0091-GA (ABN signed)

Estimate the patient’s payment: First of all, take these assumptions into account:

• 99397 = $200 (This is the practice’s established fee for the preventive service)
• 99213 = $100 (The Medicare allowable is $91, but this practice has a fee of $100 on 99213 and this is what they bill to all carriers including Medicare)
• G0101 = $40 (Medicare allowable should be billed by the practice rather than setting a practice fee that is higher than the allowable since this is only ever covered by Medicare)
• Q0091 = $44 (Medicare allowable)

First, subtract the office visit from the preventive service ($200-100 = $100),

• then subtract G0101 (100-40 = 60),
• then subtract Q0091 (60-44 = 16).

Result: In this case, the patient owes only $16 for the noncovered service. However, keep in mind that if your normal fees are less than this example, the total services you’re billing to Medicare could be greater in value than the fee for the preventive service from which all other services are a component and the patient will end up owing nothing for the noncovered service.

Heads up: The patient will still be liable for the co-pay that applies to 99213 (and any deductible she still owes).