"Welcome to Medicare" - What you need to know.

I came across this article information from a website called "Manage my Practice"  

http://www.managemypractice.com/why-you-cant-get-an-annual-medicare-physical/#more-13471

This is a brief exerpt from the article, but it clearly outlines what we need to understand as Coders for our Medicare patient's in our practice.  This has really cleared up the confusion for me, and hopefully will help you...  help your patients to understand what CMS Medicare will and will not pay for.  and as always... Happy Coding!





".....The only answer is to help patients understand what Medicare will and will not pay for and to try to match their benefits, their needs and what they are willing to pay for.
Here are the service choices defined by CMS/Medicare: "

NAME: Welcome to Medicare Visit

WHEN: Available to all Medicare patients during the first 12 months of Medicare Part B eligibility
WHAT HAPPENS: Review of patient’s medical history, risk factors, functional abilities and referrals for education or counseling. Could include an EKG or referral for an EKG. Could include screening for an
abdominal aortic aneurysm (AAA). Does not include a physical exam.
WHO PAYS: This visit has no deductible and no co-insurance, unless the patient has a screening EKG. The EKG does have the deductible and co-insurance applied.

NAME: Annual Wellness Visit

WHEN: Available 12 months after the Welcome to Medicare Visit and every 12 months thereafter
Does not include a physical exam.
WHAT HAPPENS: Review of your medical history, risk factors, functional abilities, a depression screening and a written screening schedule.
WHO PAYS WHAT: This visit has no deductible and no co-insurance.

NAME: Sick Visit (standard office visit)

WHEN: No restrictions on how often as long as there is a documented need for the visit.
WHAT HAPPENS: This is a regular office visit for an illness, injury or new problem or for monitoring of an existing problem. The three parts of a standard office visit are the HISTORY, the PHYSICAL EXAM, and the ASSESSMENT/PLAN.
WHO PAYS WHAT: This visit will apply to the deductible ($147 for 2013) if the patient’s deductible has not been met, and co-insurance will apply.




The only answer is to help patients understand what Medicare will and will not pay for and to try to match their benefits, their needs and what they are willing to pay for.
Here are the service choices defined by CMS/Medicare:

HCPCS Changes in Depo Provera Coding for 2013

New HCPCS code: 
J1050  (Injection, medroxyprogesterone acetate, 1 mg)

Deleted codes: (as of December 31, 2012)
J1051 (Injection, medroxyprogesterone acetate, 50 mg), 
J1055 (Injection, medroxyprogesterone acetate for contraceptive use, 150 mg) and 
J1056 (Injection, medroxyprogesterone acetate/estradiol cypionate, 5 mg/25 mg) 


Effective January 1, 2013, injection administration of medroxyprogesterone acetate (Depo-
Provera) should be reported using HCPCS code J1050 . Due to the change in dosage from the discontinued codes, when reporting code J1050, the appropriate dosage (measured in units) should be reported based on the specific needs of the patient.


This change means that you will code/bill the HCPCS code as J1050 x the amount units given.  (eg.  If the provider is giving 50 units then you should code as: J1050 x 50 units.  If the provider is giving 150 units then you should code as J1050 x 150 units.)  The appropriate diagnosis also needs appended to the claim.  If the provider is giving the drug for a diagnosis such as menorrhagia,  abnormal menstrual bleeding, or other gynecologic reason, the code J1050 should be reported using the exact amount of drug used per patient.  

Medical necessity should always be the driving factor for any therapy given and all orders and  documentation must be noted.

In addition, you will need to report the injection administration with CPT code 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular). However, CPT code 96372 requires direct supervision of a physician or other qualified health care professional (unless administered in a hospital setting)