Preventive service billing
Also in this section:
Preventive medicine billing, all plans except Medicare
Priority Health covers preventive medicine services listed in the Preventive Health Care Guidelines rendered to infants, children, adolescents and adults. In addition, we reimburse for other E&M services.
- View the Preventive Health Care Guidelines.
- View preventive and diagnostic service examples.
- Comprehensive preventive medicine exam: Use preventive medicine codes 99381-99387 (new patient) and 99391-99397 (established patient) to report services. Report the preventive medicine CPT or HCPCS code appropriate for the extent of the exam, which varies by age and gender of the patient.
Example: A comprehensive preventive service for a 28-year-old adult female should include additional components related to gender: Pelvic examination (including obtaining a pap smear) and breast examination.
- Reporting G0101 and Q0091: Priority Health may reimburse for a pelvic and breast exam and/or obtaining and preparing a pap test for the lab in place of, not in addition to, preventive medicine codes when only the specific components of the preventive service are performed. See criteria for reporting G0101 and Q0091.
Preventive medicine billing for Priority Heath Medicare
Priority Health covers preventive medicine services rendered to Medicare members for comprehensive preventive medicine exams.
Comprehensive preventive medicine exam: Members are eligible for one preventive medicine service per year. Verify with patients prior to providing a complete physical that they have not already had a preventive service from their primary care physician. This will avoid duplicate, non-medically necessary services; for example, when only a well-woman gynecological visit is needed.
- Use preventive medicine codes 99381-99387 (new patient) and 99391-99397 (established patient) to report services.
- HIV screenings: Priority Health covers annual HIV screenings; women who are pregnant may have up to 3 screenings during a pregnancy.
- An office visit copay may apply, but no copay/coinsurance applies to separate preventive care services.
- Follow the Medicare preventive health guidelines; see the CMS chart, below, for covered procedures and codes.
Download the Medicare Learning Network Preventive Service Quick Reference Chart (link will open in a new browser window)
Well-woman exam: Medicare offers a well-woman gynecological benefit for the female population in addition to the preventive medicine visit (commonly performed by PCP). A well-woman gynecological exam consists of a breast and pelvic exam plus obtaining of the pap smear.
- A well-woman exam is reimbursable once every 24 months.
- Services performed solely for a well woman visit can be coded as G0101, pelvic and breast exam, and Q0091, obtaining and preparing a pap test for the lab. See criteria for reporting G0101 and Q0091.
- Do not report G0101 and/or Q0091 with a preventive medicine E&M code when billed by the same provider on the same date of service.
