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Family Practice Coding Alert

Reader Questions:

Determine CPE Charge Based on 99397-G0102

Question: When we perform a digital rectal exam on the same date of service as a preventive medicine service, should we carve out the G0102 payment in the same way as we would if we were reporting G0101 with the exam? Please clarify the carve-out formula specific to G0102, if applicable.

Massachusetts Subscriber

Answer: Yes, you should reduce your fee for preventive medicine services (99381-99397) when your family physician (FP) also performs a digital rectal exam (G0102, Prostate cancer screening; digital rectal examination), as you would if she instead provided a pelvic and breast examination (G0101, Cervical or vaginal cancer screening; pelvic and clinical breast examination). The amount you should deduct depends on your physician's customary charge for the preventive medicine service.

Suppose an Indiana FP performs a comprehensive preventive examination (CPE) with a digital rectal exam for an established 65-year-old male Medicare patient who has no symptoms. The physician does not address any pre-existing conditions and normally charges $150 for the CPE. In this case, Robert Clutter, MD, Indiana Academy of Family Physicians Medicare carrier advisory committee representative, and Joy Newby, LPN, CPC, IAFP coding and reimbursement consultant, recommend billing $130 for 99397-GY with a diagnosis of V70.0 (General medical examination; routine general medical examination at a healthcare facility) and $20 for G0102 linked to V76.44 (Special screening for malignant neoplasms; other sites; prostate), which results in a total charge of $150.

Another way to look at the formula is to consider Medicare's allowable for each code. The Medicare Physician Fee Schedule (MPFS) gives 3.14 nonfacility relative value units (RVUs) to 99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual established patient; 65 years and over) and 0.56 RVUs to G0102. Therefore, the geographically unadjusted rates for these codes are $115.52 for the preventive service and $20.60 for the rectal exam.

Of course, Medicare considers preventive services noncovered, which is why you should append modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to 99397. Therefore, you will have to bill the patient for 99397. In this case, if you followed the MPFS rates, you would deduct the rectal exam charge ($20.60) from the preventive medicine service ($115.52) fee for a total patient charge of $94.92. Some practices prefer to use round numbers to make calculations easier.
Regardless of the rates that you decide on, remember that Medicare covers G0102 annually for a diagnosis of V76.44. In addition, you may bill the rectal exam code only when the physician performs no problem-pertinent E/M services on the same day. Answers to You Be the Coder and Reader Questions provided by Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.; [...]