MEDICARE PREVENTIVE SERVICES

Hello all please find below article for medicare billing and coding relating information.

Resources

·         General Medicare Preventive Services Resources

·         CMS Webpage

Annual Wellness Visit (AWV)

HCPCS/CPT Codes

G0438 – 

Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

G0439 – 

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

99497 – 

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other 

qualified health care professional; first 30 minutes, face-to-face with the patient, 

family member(s), and/or surrogate

99498 – 

Advance care planning including the explanation and discussion of advance directives 

such as standard forms (with completion of such forms, when performed), by the physician 

or other qualified health care professional; each additional 30 minutes 

(List separately in addition to code for primary procedure)

ICD-10 Codes

See the CMS ICD-10 webpage for individual CRs and coding translations for ICD-10, and

 contact your MAC for guidance

Who Is Covered

All Medicare beneficiaries who:

·         Are not within 12 months after the effective date of their first Medicare Part B coverage and

·         Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the 

      past 12 months

Frequency

·         Once in a lifetime for G0438 (first AWV)

·         Annually for G0439 (subsequent AWV)

·         Annually for optional 99497, 99498

Medicare Beneficiary Pays

G0438 and G0439:

·         Copayment/coinsurance waived

·         Deductible waived

99497 and 99498:

Copayment/coinsurance and deductible waived for Advance Care Planning when furnished as an optional element of an AWV

Other Notes

For services furnished on or after January 1, 2016, Advance Care Planning is treated 
as an optional preventive service when furnished with an AWV.
Practitioners may provide Advance Care Planning outside of the AWV multiple times in a year, but the practitioner must document a change in the beneficiary’s health for each additional service in a year. When providing Advance Care Planning outside the AWV, the beneficiary is responsible for the deductible and coinsurance.The deductible and coinsurance for Advance Care Planning is only waived when furnished as an optional element of an AWV, which requires:Billing with modifier –33 https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html(Preventive Service) on the same claim as an AWVFurnishing on the same day and by the same provider as the AWV
Refer to The ABCs of the Annual Wellness Visit for more information.

Note:-  For Additional information please go through below.

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Pain management & coding guidelines

Medicare guidelines for well women examination

MEDICARE- G0101 & Q0091

Covered Services

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Medicare covers the following screening exams along with a Well Woman Exam:

1. G0101 (Cervical or Vaginal Cancer Screening; Pelvic and Clinic Breast Examination):

a. G0101 is reimbursed by Medicare every two years, unless the patient is considered high risk, and then it is allowed on an annual basis.

2. Q0091 (Screening Papanicolaou Smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) :

a. Q0091 is reimbursed by Medicare every two years, unless the patient is considered high risk, and then it is allowed on an annual visit.

C. As per the CMS website the ICD-10-CM codes billable with the Q0091 are Z12.4,Z12.72,Z12.79,Z12.89 and Z01.411,Z01.419.

3. 82270 (Fecal Occult Blood Test) :

a. 82270 can be billed on an annual basis.
b. Per the CMS website, the appropriate code varies by carrier. An applicable code is Z12.11 Special Screening for Malignant Neoplasms; Colon.

High Risk Factors and Frequency:

 If a patient is considered high risk, then these screening tests might have done annually.

According to the CMS, the following below are listed as high risk factors for screening pap smears and pelvic exams

1.      Cervical High Risk Factors
a. Early onset of sexual activity (under 16 years of age)
b. Multiple (five or more in a lifetime) sexual partners 
c. History of a sexually transmitted disease (including HIV,HPV infection)
d. Fewer than 3 negative or any Pap smears within previous 7 years

2.      Vaginal Cancer High Risk Factors: DES (diethylstilbestrol) exposed daughters of women who took DES during pregnancy.

3.      Personal Hx of Health Hazards:

       If a patient has a specified personal history presenting hazards to health then apply the V15.89 diagnosis and the appropriate health history hazard (example: V10.3 History of Breast Malignancy). Any V15.89 diagnosis is considered high risk and makes the patient eligible for the yearly G0101 and Q0091

b. According the CMS website: The below given diagnose codes are appropriate to bill the CPT® G0101

Select the appropriate ICD10 codes : Z12.4,Z12.72,Z12.79,Z12.89 and Z01.411,Z01.419.

i.   Special screening for malignant neoplasms, cervix
ii.  Special screening for malignant neoplasms, vagina
iii. Special screening for malignant neoplasms, other sites
iv. Other specified personal history presenting hazards to health
v.  Routine gynecological exam

https://www.emedny.org/ProviderManuals/Physician/index.aspx 
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