CODING & DOCUMENTATION

If a patient requests a routine health exam rather than a “Welcome to Medicare” visit (G0402) or an annual wellness visit (AWV) (G0438 - G0439), report a preventive medicine code (99381 - 99397) with modifier GY to indicate that the service is not covered by Medicare. Additionally, a pelvic and breast exam (G0101) and Pap smear (Q0091) are covered when provided at appropriate intervals — once every two years for patients with average risk of developing cervical or vaginal cancer and annually for patients with high risk. However, since the pelvic and breast exam and the Pap smear overlap with some of the preventive service components, the amount allowed by Medicare for those services should be deducted from the amount billed to the patient for the noncovered preventive service. If a Medicare beneficiary requests a well-woman exam in conjunction with a “Welcome to Medicare” visit or an AWV, codes G0101 and Q0091 are billable and paid in addition to the “Welcome to Medicare” exam or AWV.To ensure payment, verify the date of the patient’s last claim to Medicare for these services. Otherwise, you could obtain the patient’s signature on an advance beneficiary notice before providing the services.

If you provide a test that measures hearing at the range of human speech with a pass or refer based on the testing result, report code 92551. If you provide an air-only test to determine the threshold or lowest intensity level at which a patient can hear, report code 92552. Append modifier 52 if the hearing screening is performed unilaterally.

Report code 16000, “Initial treatment, first degree burn, when no more than local treatment is required.” If the patient has a partial-thickness burn requiring dressing or debridement, report code 16020, 16025, or 16030 based on the percentage of total body surface area that is burned.

Peak flow measurement may not be separately reported. It is included in the examination component of the E/M service similar to a pulse rate or temperature measurement.

Yes. Although medical students were previously allowed to document E/M services, the Centers for Medicare & Medicaid Services recently changed the teaching physician guidelines to allow a teaching physician to verify any student documentation of components of E/M services in the medical record rather than having to re-document the work. The teaching physician must still personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed.