Medicare preventive services updates
Coverage for preventive E&M and Annual Wellness Visit
Preventive exams for Medicare members are offered under two coding structures:
- preventive evaluation and management (E&M)
- annual wellness visit (AWV)
For claims processed beginning Jan. 1, 2012, a preventive E&M and AWV are covered when billed on the same date of service. The claim should be billed with modifier 52 on the E&M claim line. This will reduce the payment to 80% for the E&M service and allow payment of the AWV.
To bill an E&M and AWV on the same date of service, documentation must support care that meets both of these exam code definitions.
Coverage for preventive visits with a PCP and OB/GYN
We cover one preventive exam each year. Often, women choose to receive preventive care from their PCP and OB/GYN. If both exams are billed with a preventive E&M code, the second billed exam will deny as member liability.
Providers offering a second preventive exam in a plan year should consider using G and Q codes to identify Pap and pelvic exams, which may not have been conducted during the first preventive visit.
New preventive health care services
Centers for Medicare and Medicaid Services (CMS) has added four new preventive health services covered for members of our Priority Health Medicare plans. These new services are:
- Screening in the primary care setting for depression in adults: Effective for dates of service on or after Oct. 14, 2011, Medicare will cover an annual screening for depression in a primary care setting. Coverage is limited to screening services and does not include treatment options for depression or any diseases, complications or chronic conditions resulting from depression, nor does it address therapeutic interventions such as pharmacotherapy, combination therapy or other interventions for depression. For more information, search “MLN Matters 7637” at cms.gov.
- Screenings and behavioral counseling interventions in the primary care setting to reduce alcohol misuse: Effective for dates of service on or after Oct. 14, 2011, Medicare will cover an annual alcohol screening and for those who screen positive, up to four, brief, face-to-face behavioral counseling interventions per year, including pregnant women. For more information, search “MLN Matters 7633” at cms.gov.
- Intensive behavioral therapy for cardiovascular disease: Effective for dates of service Nov. 8, 2011 or after, Medicare will cover one face-to-face CVD risk reduction visit annually. For more information, search “MLN Matters 7636” at cms.gov.
- Intensive behavioral therapy in the primary care setting for obesity: Medicare has issued a decision memo to identify that it will cover intensive behavioral therapy for obesity. The intensive therapy will consist of one face-to-face visit every week for the 1st month; one face-to-face visit every other month for months 2-6; and one faceto- face visit every month for months 7-12 if the beneficiary meets the 3kg weight loss requirement. Further information on this decision can be found at cms.gov.
Topics: Priority Health updates, Preventive care
