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tracylc10

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Coding annual exams for Medicare... Cringe!!

This is what I think I understand...

G0101-GA, Q0091-GA and appropriate preventive med code with modifier GY and 52. You would "carve out" the cost of G0101 and Q0091 and what is left over would be the patients responsibility. (This is if there is a ABN signed)

If the patient is also seen for a problem, would you add the problem E&M code and drop the preventive code or just add the problem E&M?
G0101-GA, Q0091-GA, Preventive code-GY-52 and 99213-25
Or
G0101-GA, Q0091-GA and 99213-25?

From what I am reading in the COBGC study guide, it states:

"Because Medicare will cover the breast/pelvic exam and Pap smear collection for eligible patients but not the comprehensive exam, you much "carve out" the fee for the pelvic/breast exam and Pap smear collection from the usual fee you charge the patient for the comprehensive exam. In other words, the charge for G0101 and Q0091 must be deducted from the usual charge for the preventive service.

Although not covered by Medicare, you must nevertheless report the appropriate preventive care code (99385-99387 or 99395-99397) with modifier GY.

Medicare similarly will cover a medically necessary sick patient visit provided at the same time as a preventive service.

Once again, you will want to be sure to attach a 25 modifier to the appropriate E/M service code billed on the same day as other services. As well you should "carve out" the covered sick visit from the total charge that includes the same-day preventive services. You would subtract the established fee for the covered problem service from the established fee for the non-covered service. You will then bill the patient the deductible/copay for the covered service, plus the cost of the non-covered service."


If there is anyone out there that understands all of this and can explain it in a way that makes complete sense, I would really appreciate your help.

Thank you in advance for taking the time to read this long message.

Tracy
 
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You actually explained the process for billing OB-GYN to Medicare very well above. To answer your question, yes you would bill the E&M with the modifier 25 is seen for a significant sick issue at the time of the well visit. I also agree with your coding with the exception of the GA modifier on G0101 and Q0091. These are both benefits of Medicare and do not require an ABN. GA indicates that an ABN was issued and signed by the patient as required by Medicare, meaning you expect the service to deny. The only service that is subject to an ABN on this date would be the Preventative Code.


G0101, Q0091, Preventive code-GY-52 and 99213-25​
 
Thank you Chelle-Lynn,

There is also a paragraph that says:
"Medicare coverage for the pelvic/breast exam and Pap smear collection are dependent on several factors, you may wish to ask the patient to sign an ABN for each of those services and append modifier GA to both codes. This allows you to collect payment from the patient if Medicare denies coverage (for instance, if the previous pelvic/breast exam and/or Pap smear collection occurred fewer than two years prior)."

This makes me want to disagree with you on the need for the GA modifier.

So other than that, you think I am doing this correctly? I just need to be clear so I can educate my providers.
 
You made a valid point on the GA modifier. In that case I would agree with the coding. Looks like you are doing great!
 
Thank you so much for your response. I really need to stop questioning myself. I've only been a coder for the last 2 years, was a medical assistant for 20 years before that. My office has me doing audits and it is very overwhelming. Again, thank you for your help.
 
A couple of issues here.
You cannot use a 52 modifiervon an E&M code and that includes preventive visit codes.
You can use a problem visit with a preventive level only if the problem is documented as an abnormal finding by the provider and not if presented as a complaint/symptom per the patient. The code for the preventive diagnosis states "without complain, suspected, or reported diagnosis".
You cannot use the Dx code for well woman (Z01.41-) with the General preventive (Z00.0-) code as both are first listed only allowed.
You would obtain an ABN for a well woman only if it is the off year which would not be covered.in that case you would use the GA modifier on the Q0091 and the G0101.
If the patient is presenting for a well woman only then you use only the Q0091 and the G0101. If the patient is coming for a general wellness visit then you use the G0438 or G0439. If you are trying to perform the annual wellness with the well woman you can use the G0438 or G0439 with the two codes for well woman however you would use the Z00.00 with the Z code for screening pap.
 
Ok, so no 52 modifier. Can you direct me on where to find the documentation that states this? It would be a reduction in service since the pelvic/breast exam and pap are being coded with G0101 and Q0091 and are usually included in a preventive exam code.

A question regarding the ABN, why would you not have them sign one every year? Wouldn't the office benefit having them be aware that there is a possibility that something that is being done could be denied, in which case you would be covered with the ABN on file to collect a payment?

I am just needing to know how a straight forward annual preventive exam (not the annual wellness G0438 or G0439) should be coded. It would be a patient that comes in for an annual pelvic/breast exam and Pap smear collection, preventive exam.

Tracy
 
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The 52 modifier is covered in the federal register. You will need to search the he web for it as it has been awhile since I found it and I no longer have the link. However only the modifiers specified as E&M modifiers can be used on E&M codes. you cannot do a full preventive and a covered well woman on the same day. You need the Z01.419 for the well woman to be covered and that cannot be used with the Z00.00 since they are both first listed only allowed codes. If you perform the noncovered full preventive with a pap then you would use the Z00.00 with the Z12.4 using the preventive E&am with the Q0091. Medicare will pay for the pap.
It is not good practice to get an ABN every time. There is a rule regarding abuse of the ABN. You need to know when it is covered. Medicare also states that the entire ABN is to be read out loud to the patient each time. And it must be specific to the service. There is an entire section in the Medicare manual for ABN use. If you do decide to capture the ABN each time then you must append the GA modifier to the service the ABN applies to. You cannot obtain the ABN "just in case". It is entirely possible that Medicare will deny the service because of the GA modifier. Without the GA modifier however and if the service is not covered then the patient will be instructed to not pay. It is a bit of a sticky wicket. You must always check to see if the timing is right for the service to be covered.
 
Thank you Debra for all of this info. I believe that AAPC is training this information incorrectly then. In the COBGC study guide it states and I am quoting this word for word:

"Medicare coverage for the pelvic/breast exam and Pap smear collection are dependent on several factors, you may wish to ask the patient to sign an ABN for each of those services and append modifier GA to both codes. This allows you to collect payment from the patient if Medicare denies coverage (for instance, if the previous pelvic/breast exam and/or Pap smear collection occurred fewer than two years prior)."

Also, I am not in a position where I get to see these before they are billed out. I am the only coder for our Ob/Gyn group and I was mainly hired to do quarterly audits. This is where I am coming up with questions, as I believe our MDs are coding these wrong. We have 18 docs and 5 offices. I am trying to learn this so that I can educate them all.

I really appreciate any info I can get on this.
 
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