Coder's Cranium

Report Picture Perfect Annual Wellness Visits With These 5 Tips

The Affordable Care Act (ACA) extended preventive coverage to more than 88 million patients covered by health insurance, and Medicare has codified that benefit in the form of an annual wellness visit. Medicare valued the new annual wellness codes based on a level 4, problem-oriented new and established E/M service. The two new codes are:

  • G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit
  • G0439 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit.

Tip 1: Apply G0438 to Second Year of Coverage

Be wary of applying these codes to new Medicare patients coming in to your physician’s practice in 2011.

The reason is that Medicare will only reimburse the initial visit (G0438) during the second year the patient is eligible for Medicare Part B. In other words, during the first year of the patient’s coverage, Medicare will only cover the Initial Preventive Physical Exam (IPPE), also known as the Welcome to Medicare exam.

Tip 2: CMS Limits G0438 to One Physician

If your FP sees the patient for the initial visit (G0438) and the patient sees a different physician for the next annual wellness visit, that second physician will only receive reimbursement for the subsequent visit (G0439), despite having never seen the patient before.

CMS has indicated that when a patient returns to the same or new physician in a third year, they might only pay for the subsequent visit, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. “It is therefore important that you convey this information to any new physician the patient sees.”

Tip 3: Add Preventive Service Codes, If Performed

You can bill the new annual visit codes in addition to any other preventive service, such as G0102 (Prostate cancer...

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January 18, 2011
Coding Challenge

Medicare Repeat Pap Smears: Find Out If 99000 Is OK

Hint: Abnormal versus insufficient cells mean different diagnosis codes.

When a patient returns to your office for a repeat Pap smear, you’ve got to weigh your options of E/M and specimen handling codes, as well as diagnosis codes. Take this challenge to see how you fare and prevent payment from slipping through your fingers.

Question 1: When a patient comes in for a second Pap smear, what CPT code(s) should you apply and why?
 
Question 2: Will you receive reimbursement for handling the repeat Pap smear? Why or why not?

Question 3: If the patient comes back in for a Pap smear due to abnormal results, what ICD-9 code(s) should you use and why?

Question 4: If the patient has a repeat Pap because the lab did not have enough cells in the specimen to interpret the results, what ICD-9 code(s) should you use and why?

Answer 1: Here’s What CPT Codes
 
When the patient comes in for a second Pap smear, submit the appropriate E/M office visit code (99211-99215). You will probably be able to report 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) for this visit becausethe patient likely will come in only for the Pap smear and CPT does not include a specific code for taking the Pap. Code 99212 carries 1.08 relative value units (RVUs), unadjusted for geography. That translates to about $31 for this visit (using the new conversion factor of 28.3868).
Answer 2: Handling the Specimen Depends on Payer


Some private payers will reimburse for handling the repeat Pap smear specimen (99000, Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory). But Medicare carriers consider the collection and handling part of a problem E/M...

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August 12, 2010
Coder's Cranium / ICD-9

Collect HPV Pay with Proper Screening vs. Reflex Diagnoses

Align ‘medical necessity’ with ICD-9 instruction.

Ordering a human papillomavirus (HPV) screen with a Pap test isn’t the same as ordering a reflex HPV screen following an abnormal Pap. Although ICD-9 instruction and coverage rules might appear to be at loggerheads, our experts can show you the way out.

Question: Should the physician order a screening and/or reflex HPV Pap test (such as 87621, Infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, amplified probe technique) with V73.81 (Special screening examination for human papillomavirus [HPV])?

What you stand to gain: “Many ‘V’ codes are paid as part of a screening benefit for patients who have those specific benefits,” says Tina Burkhalter, billing manager with SouthEastern Pathology in Rome, Ga. On the other hand,

“tests ordered with diagnostic codes tend to go to the deductible,” she says. “We hear from patients complaining that they must pay for the HPV test because their insurer tells them we used the ‘wrong’ code.”

Medical Necessity Points to 795.0x

Although no national coverage policy exists for screening HPV testing to evaluate cervical cancer risk, many payers follow the consensus guidelines recommended by the American Society for Colposcopy and Cervical Pathology (ASCCP).

A core ASCCP recommendation is to screen for high-risk HPV DNA in patients over the age of 20 years with a Pap cytologic result of 795.01 (Papanicolaou smear of cervix with atypical squamous cells of undetermined significance [ASC-US]). The guidelines also address the role of HPV with other Pap outcomes in special populations, such as recommending reflex HPV testing for postmenopausal women with cytologic findings of 795.03 (Papanicolaou smear of cervix with low grade squamous intraepithelial lesion [LGSIL]).

Key: If your payers have adopted any or all of these guidelines, you’ll need to report the Pap findings, such as 795.01, to show...

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June 10, 2010