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GI - Preventative exam

Thomas Posted Tue 13th of January, 2015 17:55:55 PM

We had a patient follow up in the office for his yearly preventative exam. We are not his primary care physician but the physician has agreed to do his yearly exam since he knows the patient. Billed Medicare with CPT 99214 and diagnosis code V70.0, which the claim was denied by medicare as non covered service because it is a routine/preventative exam. Would this be covered as medicallly necessary if we use diagnosis code V72.83?

SuperCoder Answered Wed 14th of January, 2015 13:46:35 PM

Thanks for your question. Please allow additional time to research your question.

SuperCoder Answered Wed 14th of January, 2015 13:46:35 PM
SuperCoder Answered Wed 14th of January, 2015 23:32:01 PM

Thanks for your patience. Review the procedure code range 99391-99397 (established patient preventative medicine services) and select the proper code based on the age of the patient. If your provider completed an annual exam this would be a more appropriate option for billing. Hope this helps.

Thomas Posted Wed 04th of February, 2015 16:39:38 PM

I received another Medicare denial when refiling claim with CPT 99397 and Diagnosis code V70.0 on the advice of Supercoder. Confused now as to what to use for CPT/DX codes. Please note we are a Gastroenterologist and not his primary care provider. Thanks -

SuperCoder Answered Wed 04th of February, 2015 21:07:16 PM

Medicare does not cover 99397; Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older. Since your provider did not cover any problems during the visit, this is the code that you should be billing and not the established visit codes. Medicare does have the G codes for annual wellness visits G0438 and G0439 but given the specific items the providers have to complete during these types of visits, it is unlikely that a specialist will qualify for billing these codes. 99397 is considered the routine physical, annual physical, well exam, etc. You should review the guidelines for billing the wellness exams and see if your provider's documentation will hold up for billing the G codes.

You mentioned the diagnosis code V72.83; Other specified pre-operative examination in your first post; was the patient being examined prior to a procedure? Medicare and most other payers see any workup or evaluation prior to a procedure as being included in the procedure and will not reimburse for the visit. Medicare stakes the same stance.

See the attached MLN article for specific guidelines for Annual Wellness Visits to determine if your provider can bill this code.

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