Wiki Preventive Exam with no ABN

[debellis59]

Unfortunately, the clinic where I work doesn't have Medicare patients EVER sign an ABN. Therefore we are losing a lot of money. However, that isn't the issue at the moment. If we have a Medicare patient come in for a Well Woman Check with Breast/Pelvic exam and PAP, what is the proper use of the GZ modifier? We currently carve out the B/P exam & Pap, bill Medicare for those, and w/o the balance of the 99387 or 99397 at the reduced price so Medicare never even sees the CPT for the actual exam, only the Q0091 & G0101. Should the GZ modifier be used on the bill in that instance? Any help you can provide is appreciated. I see lots of examples on how to code when the ABN is signed, but nothing concrete when it isn't.

 

[kathyvl74]

our office doesn't use GZ modifier
we bill g0101 and q0091 with a GA modifier if we have a signed waiver. if we do not have a signed waiver we bill these same codes without the GA modifier. If the patient has exceeded their routine benefits Medicare will then deny these codes as a contractual adjustment.
we also bill the 99387 or 99397 codes with modifier 52 and GY. GY tells Medicare that waiver not needed. The patient pays for this part of the well exam not covered by Medicare. You say you carve this part out but write it off? You should collect payment from patient

 

[RebeccaWoodward*]

Unfortunately, the clinic where I work doesn't have Medicare patients EVER sign an ABN. Therefore we are losing a lot of money. However, that isn't the issue at the moment. If we have a Medicare patient come in for a Well Woman Check with Breast/Pelvic exam and PAP, what is the proper use of the GZ modifier? We currently carve out the B/P exam & Pap, bill Medicare for those, and w/o the balance of the 99387 or 99397 at the reduced price so Medicare never even sees the CPT for the actual exam, only the Q0091 & G0101. Should the GZ modifier be used on the bill in that instance? Any help you can provide is appreciated. I see lots of examples on how to code when the ABN is signed, but nothing concrete when it isn't.

This is a statutorily non-covered service (99387)...

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. The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury.

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

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[debellis59]

Thank you both very much.