Tuesday, August 24, 2010

Wellness + Eval Mgmt = CARVE OUTS!

Hi to all!!!

I found this on the WPS site for Medicare (out of Wisconsin) This is a terrific resource article in explaining what we (as coders) need to do for Wellness, E&M services and how to "carve" them out for coding compliance & our Medicare beneficiaries.

"Carving" has always been a confusing & difficult issue for coders and providers to understand, document and bill for correctly.

I hope this helps you out. And again... Please let me know if you have any questions, concerns, issues, or just want to leave a comment. I'm always here to help. THANKS & HAPPY CODING!



In the course of performing a non-covered preventive or "annual" exam, providers often perform preventive or other services that should be covered by Medicare Part B. However, many providers are either not submitting claims, or are incorrectly billing for these covered services. Preventive medicine evaluation and management visits, or "annual exams," are comprehensive exams for the sole purpose of preventive care. These services are represented by CPT codes 99381 through 99429, and are based upon age and whether the patient is new or established.

Although Medicare Part B does not normally cover preventive or screening services, there are some preventive exam/services that are covered.

Examples of covered services include: Prostate Specific Antigen (PSA); prostate exams; and breast and pelvic exams. Many of these services could be "carved out" of an age appropriate "annual exam" and be billed to Medicare Part B.

(Please see the CMS Website at http://www.cms.gov/mlnedwebguide/25_emdoc.asp? link to website outside of <span class=WPS Medicare" border="0" height="14" width="17"> for a listing of covered services and appropriate billing guidelines.)

Even when the main purpose of the visit was for a preventive exam, Medicare may cover the monitoring of a chronic illness or the treatment of a significant new issue. For example, any part of the history, physical exam, or plan portion of the "annual exam" that has been performed to address chronic or new issue(s), can be "carved out" of the non-covered preventive exam for coverage by Medicare.

In order to "carve out" either a covered preventive benefit or a service performed to monitor/diagnose an illness or problem during a preventive "annual visit," the provider must first bill the appropriate preventive medicine code.

All appropriate HCPCS code(s) for covered preventive service(s) that have been performed during the "annual exam," should be billed on the same claim as the preventive visit. Any new problem or chronic illness directly addressed during the preventive visit should be billed at the appropriate level of evaluation and management (E/M) code for that issue on the same claim as the "annual exam."

To "carve out" a covered E/M visit from a preventive visit, only those elements in the history, exam, and plan that directly address the chronic illness or new problem may be used to determine the appropriate level of E/M.

Elements of the history, exam, and plan performed strictly as part of the age appropriate exam, and not directly related to treatment for the chronic illness or new issue, would not be considered medically necessary in determining the appropriate level of covered E/M service.

When the applicable elements have been identified, the provider should use the E/M coding guidelines to determine the appropriate level of E/M service to bill to Medicare Part B. (The documentation requirements for E/M services can be found on the CMS Website at: http://www.cms.gov/mlnedwebguide/25_emdoc.asp? link to website outside of <span class=WPS Medicare" border="0" height="14" width="17">)

When billing a preventive visit with "carve outs," the beneficiary can only be billed for the difference between the standard fee for the preventive service and the amount that Medicare will cover. For example:

CPT 99397-est. patient preventive visit standard fee = $100
CPT 99213 (add Modifier 25)-est. patient, Office Visit = $30
G0101-Cervical CA screening w/Breast & Pelvic exam = $30
Total amount not covered by Medicare = $40*

*This is the amount that can be directly billed to the beneficiary for the preventive service after the "carve outs." (The fees listed above are strictly hypothetical and for example purposes only. They do not directly correspond with the actual Medicare Fee Schedule for these services.)

Please note that all deductibles and co-pays still apply for those services that are covered by Medicare with the following exceptions:

  • HCPCS G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and G0102 (Prostate cancer screening; digital rectal examination. For these services, the deductible, but not the coinsurance, is waived.

  • HCPCS code Q0091 (Screening papanicolaou smear; obtaining, preparing and conveyance of the cervical or vaginal smear to the laboratory) The PAP test, itself, is a clinical laboratory service and, therefore, is subject to section 1833 of the Act, which requires 100% reimbursement. As the coinsurance applies to HCPCS Q0091 (handling of the specimen) but not to the actual test, the provider may bill the patient for coinsurance for Q0091.

  • The actual lab tests HCPCS G0103 [PSA], P3000/3001 [Pap smear] and G0107 [Fecal-Occult Blood] have neither deductible nor coinsurance applied.

When performing a combination of a preventive exam, a covered exam, and, for example, Q0091/ G0101 or G0102, the provider must "carve out" the covered services from the amount he/she bills to the beneficiary. The beneficiary would be responsible for only the preventive exam, coinsurance for Q0091/G0101 or G0102, and coinsurance for the covered portion of the E/M (assuming that all deductible has been met). If there were an outstanding deductible, it would be applied only to the covered part of the E/M.

To illustrate, if the beneficiary had the entire $100 deductible outstanding at the time of the service, and the Medicare allowed amount for the E/M was $50, Medicare would apply the entire $50 for the payable part of the E/M to the deductible, and pay nothing.

Since the deductible would be waived for either the pelvic examination and associated handling of a PAP specimen or the prostate examination, Medicare would pay the full 80% for these services.

The provider could then bill the beneficiary $50 (for the E/M), the 20% co-pay for Q0091 and G0101, or G0102, and the cost of the preventive exam.

Please note that all deductibles and co-pays still apply for any other services that are covered by Medicare. (See National Coverage Provision (NCP) PHYS-001 and National Coverage Determination (NCD) GU-003 for additional information on "carve outs."

In summary, when addressing a covered preventive service(s) and a chronic illness or new issue, both should be included in the same billing with the preventive visit.

In those cases, the provider should bill the appropriate preventive visit code, the HCPCS codes for the covered preventive services, and the appropriate level of covered E/M service on the same claim. Only one unit should be billed for each service.

In "carve out" situations, when multiple E/M services are billed on the same claim for the same date of service, the use of Modifier 25 on any covered "carved out" E/M services is necessary.

The next time you perform a preventive visit/"annual exam," take a second look to determine whether there are elements of that preventive service that can be "carved out." This will ensure that you and the beneficiary are receiving the Medicare coverage to which you both are entitled.

The information in this article is based on the references presented. In the event of any discrepancy with the information in this article, applicable National Coverage Decisions are the final determinants.

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