Wiki Medicare G0438/G0439 & G0101, Q0091 Billing

[n2horses]

I work for an internal medicine practice that has been billing a combination of codes together on the same DOS and receiving a ton of denials for inclusive services/ bundled services, or PR-119 benefit max reached.

I have done quite a bit of research on the proper coding of the claims for services but need some assistance in providing proof of proper billing of these services.

When the provider sees a patient for an annual physical and PAP, it is being coded as:
99397
99000
G0101
Q0091 with Dx Codes V70.0, V72.31, V76.47 on all the CPTs. (pre- ICD-10)
Medicare is denying the 99397, 99000, and paying on the G&Q codes, leaving the 99000 as CO-97 and the 99397 as PR-119. There is no ABN on file.

I am aware that 99000 should not be billed to Medicare and is covered in the Q0091 code.

When the provider sees the patient for an AWV G0439, it is also being billed with G0101 and Q0091 with the same above DX codes. Either the G code is denied, or the Q codes or denied, but the claim never pays in full for all 3, regardless of dx code. (I am looking for a reason to deny based only on the cpt selection- billing together on same DOS) 99% of these claims are billed with low risk DX codes, and I am aware that Medicare only allows the PAP annually for high risk, and every 2 years for low. Some of these codes deny due to frequency issues.

It is my understanding that Medicare does not allow the G0438/9 to be billed and paid on the same DOS as G0101 & Q0091.

It is also my understanding that Medicare does not pay for 993397 codes for physicals with the G0101 & Q0091, and the Carve Out rule should be observed where the patient pays the difference for the physical = physician fee for the physical less what Medicare pays for the G & Q code PAP combo. An ABN should also be issued and signed by the patient prior to services rendered for this situation.

Can someone please confirm that G0438/9 cannot be billed and paid in addition to G0101 & Q0091 on the same DOS?
If it can be paid, please advise on any modifiers or coding/billing tips to get these combo code claims paid.

This is a huge issue for this practice and clogging up our follow up. Thanks!!

 

[lori mitchell]

Hi. I'm not aware of any guideline preventing billing of an AWV (G0438 or G0439) at the same encounter as the screening pelvic exam and Pap collection (G0101 & Q0091). Have you checked with your region's MAC in case they have some unique guideline for that beyond what CMS has published?

Also, my understanding is that an ABN is not required for preventive codes 99381-99397. Medicare considers these to be statutorily noncovered services, so the patient is liable for that particular service regardless of whether an ABN was signed or not. When the 99381-99397 is performed at the same encounter as the G &/or Q services, the carve-out process you described is applied so that the patient is essentially not double-charged for the breast & pelvic exam & Pap (which are actually inclusive parts of the 99381-99397 out in the non-Medicare world).

I believe Medicare recommends that you notify the patient ahead of time that the 99381-99397 is not covered and will result in patient liability, but my understanding is that no ABN or other written notice is actually required to allow you to collect that charge from the patient. Hope that info is helpful.

 

[Cindy01]

Medicare Physical/Provider Based

Does any one bill Medicare Physicals that bill provider based? If so, do you send your physical to Part B? Also, if you bill the G0439 out, before the G0438 will you get paid?