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Answers to physician questions about preventative services in a primary care setting
Q: I work for a family medicine practice, and we have women, usually not Medicare patients, come in frequently for their pap and pelvic. Unfortunately, we don’t know if they’ve had another preventive exam in the last year or if the patient wants her OB/GYN to perform the exams. How do we bill for these situations?
A: This happens frequently in primary care practices: The patient sees her primary care physician (PCP) or family physician for her annual physical exam. However, she wants her pap and pelvic exam performed by her OB/GYN or a female physician.
Women’s preventive health has always been an issue because insurance carriers usually pay for only one preventive service in a calendar year.
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When a patient comes in for her annual physical exam and she is not covered by Medicare, you need to ask her if she plans to have the annual exam with pap, pelvic and breast exam. If the answer is yes, then the physician would perform it and choose the preventive code based on the patient’s age and whether she is a new or established patient.
If the patient decides she wants her pap and pelvic performed by her OB/GYN, this is when the conversation should begin regarding what service the PCP will perform and billing for.
Here are a few examples:
Patient comes in for her annual preventive exam with pap and pelvic but is menstruating today so she wants to wait until next week for the pap and pelvic. How do you bill for this?
Bill the appropriate 9938x or 9939x code once, which will cover both visits. You would bill this only once even though the patient had a second visit because you have already been paid for the service; it just wasn’t completed until the following week.
A patient comes in for her annual preventive exam, but wants to see her OB/GYN for her pap and pelvic. How do you bill for this?
You can bill the appropriate 9938x or 9939x code and the visit may be paid; however, insurance carriers usually do not pay for a second preventive service, in which case the patient may be responsible for payment. The American Congress of Obstetricians and Gynecologists “Frequently Asked Questions,” 5th edition, states that the patient should be aware of a charge and the patient may be responsible if the only code available is a preventive code. If the patient is going to her
OB/GYN for a pap, pelvic, and breast exam, payment should be worked out with the patient before performing any examination.
Bottom line: The patient needs to decide who will perform her annual preventive physical exam, her PCP or OB/GYN. If she wants an examination by both physicians, then the patient likely will be responsible for paying for one of the visits.
Q: We have recently received denials when billing for the pneumonia vaccine. Should we appeal or write it off?
A: You are not alone in receiving denials. This is likely due to your office following the Advisory Committee on Immunization Practices’ (ACIP) recommendation that the initial pneumococcal (pneumonia) vaccine and a booster one year later for all adults 65 years and older, regardless of health risk. Medicare is denying payments because the program only reimburses for pneumonia vaccinations every five years.
Even though ACIP has changed its recommended vaccination schedule, Medicare’s policy has not changed in response. Medicare only allows contractors to reimburse physicians for a second pneumococcal vaccination 5 years after the initial vaccination, and then only for those at highest risk.
Unfortunately, clinical guidelines coming from organizations such as U S Prevention Task Force, ACIP, and the Centers for Disease Control and Prevention do not change coverage guidelines for government and third-party payers.
Coverage and payment guidelines come from government and third-party payer processes and do not always coincide with clinical recommendations. Therefore, you should always check payer guidelines.
In addition, I suggest you check your local Medicare carrier’s website for more information.
The answers to our readers' questions were provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to firstname.lastname@example.org.