Getting reimbursed for preventive well woman exam claims is tricky – not all third-party payers reimburse for these services and the coverage rules vary for the payers that do. You can’t afford to mess up the ABN or the allowed codes. Remove barriers to get the reimbursement you deserve by following a handy step-by-step guide.

1. Provide ABN for Medicare Annual Physician Exam

Medicare does not cover a full physical exam and patients are responsible for the cost. You can bill the exam to the patient or some secondary insurers cover the exam. Be sure to inform patients that the exam is not covered.

Some Medicare patients may refuse the full comprehensive preventive service when they learn routine physicals are not covered. Provide patients with an advance beneficiary notices (ABNs). Inform patients of what well woman exam charges they will be financially responsible for when their carrier denies coverage.

Tip: Design a dedicated ABN form for your practice. This preprinted encounter form should contain all the documentation required for coding and billing. Include any other information sheets that will help you explain coverage issues for preventive medicine visits to all your patients, but especially to Medicare patients. You still need to explain the coverage and options in plain English to the patients for ABN compliance.

2. Code the Preventive Medicine Services

A well woman exam is a preventive medicine service which you can process with evaluation and management (E/M) codes 99381-99429.  To better understand these codes, keep in mind:

• CPT codes 99381-99397 for comprehensive preventive evaluations are age-specific, beginning with infancy and ranging through patients age 65 and over for both new and established office patients. Documentation requirements for a preventive visit such as an “annual physical” include an age and gender appropriate history and physical examination, counseling or anticipatory guidance, and risk factor reduction interventions. CPT codes for immunizations and ancillary studies such as laboratory and radiology are reported separately.
• CPT codes 99401-99409 report counseling risk factor reduction and behavioral change intervention services provided at an encounter separate from the preventive medicine examination. Individual preventive medicine counseling codes 99401-99404 are used to report counseling services in areas such as family problems, diet, and exercise.
• CPT codes 99406-99409 are for individual behavior change interventions. These services are billed for patients with a behavior typically regarded as an illness, such as smoking or obesity.
• CPT codes 99411-99429 are for group counseling and other preventive medicine services.

3. Check for Preventive Service Documentation

Documentation for the preventive visit should include:

• A comprehensive history and physical exam
• A descriptive status of the patient’s chronic, stable problems that aren’t “significant enough to require additional work,” according to CPT
• Notes on how you’re managing the patient’s minor problems that don’t require additional work
• Notes concerning age-appropriate counseling, screening labs, and tests
• Orders for vaccines appropriate for age and risk factors

4. Reserve the CPT Mammograms Codes for X-Ray Center

Breast cancer awareness has led to more women seeking mammograms as part of their well woman visit. A screening mammogram is done to detect lumps or abnormalities when there aren’t any current cancer signs or symptoms. Your doctor may order the mammograms usually two x-rays of each breast. A diagnostic mammogram is done when a lump or symptoms already exist. These generally have more x-rays than a screening. When reporting mammograms in 2019, the radiology center uses these CPT® codes:

• 77063 – Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
• 77065 – Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
• 77066 – Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral
• 77067 – Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed

Also, report G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066), when appropriate.

5. Instate Strong Practice Management Policies

Here are some additional important coding and claim processing points to ensure accurate preventive medicine service reimbursement:

• Include major third-party coverage policy, coding and documentation training for all new staff who interact with patients and provide patient preventive medicine service. Stay current with major payer preventive medicine coding and billing regulations. Just a small change will affect the claims submission process and reimbursement.
• Incorporate preventive medicine services in ongoing compliance monitoring and education activities. Audits may also assist in identifying missed opportunities for reporting same-day preventive care in chronic or new illness visits as well as promote appropriate coding and billing practices.
• If a patient requests that staff manipulate diagnostic and procedure codes (which were submitted correctly to the carrier the first time) to prevent paying for non-covered preventive services, emphasize that staff adhere to standards of ethical coding. Inform patients that this type of practice would constitute a false claim and explain the ramifications of fraud.
• Take special care to link screening diagnosis codes to screening procedure codes; otherwise third-party payers will deny payment even if the screening service is a covered one. Likewise, link a CPT diagnostic procedure code to an ICD-10-CM diagnosis code for a problem or symptom in order to meet the medical necessity requirements and receive payment.
• When scheduling patient visits, clearly identify the reason for the visit. For example, determine whether the patient expects to receive a preventive medicine visit only or a same-day preventive medicine and a problem-oriented visit.

6. Train to Overcome Coding Challenges for Combined Visits

Billing for a well-woman exam gets even more complicated when you want a preventive service and problem-oriented office visit occur at the same encounter. When a woman comes in for a well-woman visit and presents with a new illness during the office visit, treating this new illness during the preventive visit creates coding and reimbursement challenges under some third-party preventive medicine payer policies.

You can’t afford to mess up the documentation for this encounter or add the wrong modifier to your claim. In this online training session coding expert Bridget Olga Smalls, CPC clarifies how to rise to these and other challenges, and she provides practical coding tips that you can put to use right away!

Commonly Purchased Online Trainings and Resources