obgyn visit and Medicare

[russelltw]

This is the first time I have had this issue come up, but looking for some guidance if anyone else has had this experience.

Client starts medicare in 2018, goes to ob-gyn and Medicare declines some of the charges leaving her with a bill of $300+.

The codes were:
99397 (Preventive Check up) - not covered
G101 (Breast and Pelvic Exam) - covered, once every two years

The office had client sign an Advance Beneficiary Notice of Noncoverage (ABN). Office is now billing client $300+ for visit. Wondering if there was a coding issue, or if client is stuck with bill.

 

[WCMason]

This is the first time I have had this issue come up, but looking for some guidance if anyone else has had this experience.

Client starts medicare in 2018, goes to ob-gyn and Medicare declines some of the charges leaving her with a bill of $300+.

The codes were:
99397 (Preventive Check up) - not covered
G101 (Breast and Pelvic Exam) - covered, once every two years

The office had client sign an Advance Beneficiary Notice of Noncoverage (ABN). Office is now billing client $300+ for visit. Wondering if there was a coding issue, or if client is stuck with bill.

When Medicare added wellness visits (initial and annual) as a result of ACA they created a new set of procedure codes for them different than the preventive services codes for those not on Medicare. Those 993– preventive codes are never covered for someone on Medicare but the new codes may work depending on what went on during the visit. These Medicare preventive codes have a G prefix. So it’s likely a coding issue and doc should be asked to refile claims.

 

[russelltw]

Thanks WCMason!

 

[somarco]

Rusty, your area may be different but many GYN's in our area do not participate in Medicare. Wife's GYN has a sign at check-in stating they do not take Medicare.