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   RE: Medicare coding
 From: Jeff Huotari
 To: Member Forum
 Posted: 02-24-2017 17:21
 Message: I'm responding here only because I just had a conversation about the 364 day issue with a partner, coder and receptionist about this last week.

A partner had an AWV on her schedule that was less than 365 days from the last.  She asked me if it could be done/paid for. I told her my understanding was it had to be 365 days or more from the last visit, so she chose to cancel the patient.  It was just minutes before the visit, so the patient may not have been happy.  Afterword, the receptionist said she had scheduled the patient because she was told that if it's within the same month as the visit a year ago it could be scheduled.  So that got me looking, and she is correct:

Page 6

"Medicare covers an AWV for all beneficiaries who are no longer within
12 months after the effective date of their first Medicare Part B coverage
period and who have not gotten either an IPPE or an AWV within the past
12 months (that is, at least 11 months have passed following the month in
which the IPPE or the last AWV was performed)."

So, for example, if they had an AWV Feb 24, 2016, you could next do an AWV Feb 1, 2017 or later.  Anybody ever tested this?

Jeff Huotari
Original Message:
Sent: 02-23-2017 20:53
From: Melissa Weakland
Subject: Medicare coding

This has been nagging at me and I finally made time to look- 

I've billed -13 with 25 modifier (paid 61.71)  then G0438 for annual wellness (paid 182.42)  then G0101 for pelvic (no modifier and paid 40.71) and Q0091 for pap (no modifier and paid 49.00)

so there it is - doable and paid.

I have discovered modifiers -25 ONLY on the -13 or -14 ; if put on anything else you don't get paid and I don't think a reason really given...

haven't been paid when for breast exam without pelvic.
And have to be very careful age or won't be covered.

Melissa Weakland MD
Ballard Neighborhood Doctors
Seattle WA
IMP since 2007
Original Message:
Sent: 01-23-2017 12:44
From: Michael Safran
Subject: Medicare coding

I find pure Medicare fairly straight forward, re combining E/M codes with the AWV.      Like Melissa, I attach a -25 modifier to the E/M code.  No problem being reimbursed, except when it is only 364 days or less from last AWV.

I didn't think Medicare covered the G codes for pelvic exam at same time as AWV.  If others have found a way, I would like to hear it.    

Medicare Advantage plans are more problematic, since they seem to have their own rules.  

Mike Safran

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