Medicare and the Physical Exam; Combining Two Services

Medicare and the physical exam

Q: I understand that regular Medicare does not pay for a physical exam. Does it matter if patients have Medicare Advantage Plans? I have been under the impression that original Medicare and Medicare Advantage Plans do not cover CPT 99381-99397. Is this correct?

A: You specified "physical exam" in your comment. I assume you are referencing the fact that the Medicare Annual Wellness Visit (AWV) services clearly don't include an exam. This is true.

However, it has been my experience in the last couple of years that most physicians are coming around to the notion that an AWV billed along with a problem oriented E&M will accomplish a couple of things. First, remember that for years providers have been in effect "giving away" the overall preventive service. You've been doing these services along with chronic disease follow-up visits and billing the combined service 99215, which is pretty obviously a work-around. Still, often two services are provided, and only one billed.

Now you can do whatever disease management is needed; take a comprehensive history update, including the assessment of impairment and risk factors, and the other odd bits of the AWV; perform your comprehensive exam; and at the end of the day, you've done a "CPE" and E&M, and gotten paid for both, and done what needed to be done.

But yes, to your point - the "physical exam" is not specifically covered, but it never has been.

As to the Advantage Plans - most pay for both the AWV and an E&M together, some may not. No Medicare plan pays for the 99381-99397 codes that I am aware of. I hope that helps.

Combining two services

Q: One of your articles (May 2011) talks about combining a preventive and a medical management visit on the same date of service. If the patient has no copay for preventive services, how do you explain that the patient will have a copay for the medical management portion? Do you use a modifier? If so, which service gets modified and what is the modifier you use?

A: Please read the April 2012 article that covers similar ground. It is crucial that when billing two services the patient understands that two services are being performed - you must communicate this to him.

The issue of the copay is a perfect example of why this needs to be communicated - so that the patient understands why he needs to pay something. To explain what is happening to the payer, you append a -25 modifier to the medical management visit code.

Pap smear and preventive services

Q: I've got an OB/GYN practice that has been billing a preventive service 99394-99397 in addition to a Q0091 or G0101 for the Pap smear. Anthem has said that the Pap smear is included in the preventive code and shouldn't be billed separately as an unbundled code. It is demanding money back from some visits that were billed this way. Can you help clarify?

A: I would tend to agree that the G0101 is included in the 99394-99397 codes as it describes the pelvic and breast exam, and the preventive codes 99394-99397 do state age and gender appropriate physical exam.

Whether the G0091 (obtaining a Pap smear) is included is somewhat debatable - but you can count on most payers to "bundle" something if it is at all reasonable to do so. And here it is easily arguable that it be included.

Remember that the G-codes and Q-codes are Medicare's answer to prevention, even including its new AWV codes. Traditional Medicare has never paid for the 99397 and 99394 series, and the G0101 and Q0091 were a way to get paid for specific cancer screening for Medicare patients without the "whole nine yards" of prevention.

When you did bill this way to Medicare, the patient paid the 99394-99397, so Medicare still only paid for one service.

A commercial payer is sure to see this as duplicative coding. The plot would thicken if this Anthem plan were a Medicare replacement or Advantage plan.

IV infusions

Q: How do we bill for an IV infusion of pain medications that a patient receives in the office for migraines? Do we just bill for the medications or can we bill based on time (hour or minutes)? Can we also bill for all the supplies pertaining to the IV infusion?

A: The CPT codes 96365 through 96368 cover IV infusions. They are based on time and some variable relating to whether the infusion is an additional, sequential, or concurrent infusion. The medications are not included in the code - these codes identify the service of administering the infusion. Bill the medications or agents using J-codes (typically) from the HCPCS Level II book.

The section guidance in CPT that precedes the infusion section outlines the standard items included in an infusion code: local anesthesia, IV start, access to indwelling, IV, subcutaneous catheter or port, flush at conclusion, standard tubing/syringes and supplies.

Note that the word "supplies" is included. If you think that you have used a supply item that could be considered outside the term "standard," then you might want to bill for that supply using an additional HCPCS code. This is generally done only for expensive and somewhat unusual supplies. But don't be surprised if the denial says "bundled."

Additional codes

Q: I have a coding question from a neurology practice. When coding for Parkinson's 332.0, is it common practice to also code for tremors, rigidity, bradykinesia, postural instability, and gait abnormalities? All these symptoms would be part of the disease process of Parkinson's and would not need to be coded - is this correct?

A: This is correct. The Official ICD-9 Guidelines for Coding and Reporting, Appendix 1, Section 1, B. 7, covers conditions that are an integral part of a disease process. It states: "Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes unless otherwise instructed by the classification."

In the Tabular section of ICD-9, under 332 for Parkinson's disease, there are no section or code-specific instructions that ask you to code additional codes for signs or symptoms.

There is also a rule that states that additional signs and symptoms that may not be related routinely with a disease process should be reported separately. So it is up to the physician to determine "routine association."

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the June 2012 issue of Physicians Practice.