Clarification of Carve-Outs for Preventive Services
Occasional questions have come to us from readers of the "Carve-out Preventive Services" article published in the May 2004 Communiqué. As the carve-out concept is new to some providers, we will attempt at this time to clarify issues that have been raised.
Medicare may cover the annual monitoring of a chronic illness or the treatment of a new issue, even when the main purpose of a visit is for a preventive exam. For example, when any part of an annual exam is performed to address chronic or new issue(s), that part of the service can be carved out of the annual exam, and can be billed for coverage by Medicare.
An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented Evaluation and Management (E/M) service, should not be reported. (Refer to the current CPT Code Book for Preventive Medicine Services.)
To correctly carve out a covered preventive benefit and/or the service performed to monitor or diagnose an illness or problem during a preventive "annual visit," the provider must first bill the carved-out portion of the annual visit at the appropriate evaluation and management service level. That portion of the visit applies to the treatment of the new or chronic problem. All appropriate HCPCS code(s) for the covered preventive service(s) performed during the "annual exam" and the preventive visit should then be billed on the same claim.
Please be aware that the CCI edits bundle G0102 (Prostrate Cancer Screening; digital rectal examination) into all E/M codes except the preventive medicine services (CPT 99381 through 99429) or HCPCS codes G0181 and G0182. In the case of a preventive E/M service and a non-preventive E/M code billed with a 25 modifier, HCPCS G0102 cannot be individually reimbursed. This, however, is the case with only G0102.
CMS has determined that HCPCS G0102 is to be bundled into the non-preventive portion of the E/M service(s) that has been billed for that encounter. In that case, G0102 is not a separately payable service. This is true whether or not a preventive E/M service has also been billed for the same encounter. If only a preventive E/M has been billed for the encounter, and the elements for G0102 have been performed, HCPCS G0102 may be carved out from the preventive E/M service and may be billed separately.
The example on page 12 of the May 2004 Communiqué illustrated a well-documented established patient office visit (CPT 99213) and a cervical cancer screening (G0101) that were carved out from a preventive annual exam. Only HCPCS G0101 can be carved out, in addition to the appropriate level of E/M visit necessary for the treatment of a new or chronic condition, from a preventive E/M service. If HCPCS G0102 had been billed, that service would have been bundled into the non-preventive portion of the encounter, and could not have been billed separately along with the non-preventive E/M service, when carved out of the annual exam.
Please remember, when billing a preventative visit with carve-outs, the beneficiary can only be billed for the difference between the standard fee for the preventative service and the amount that Medicare will cover for the carve-outs. Refer to the May Communiqué article for current exceptions to deductibles and co-pays.
Finally, the example on page 12 incorrectly showed HCPCS G0101 being billed with a Modifier 25. Only the carved-out non-preventive E/M service should have been billed with the 25 modifier. Billing G0101 with a 25 modifier will cause G0101 to be denied for the reason of an incorrect modifier. We apologize for any inconvenience this misinformation may have caused.
As always, applicable National Coverage Decisions (NCDs) (available on the WPS Website at
http://www.wpsmedicare.com/part_b/policy/index.shtml), Medicare Regulations, and CMS rules are the final determinants in the case of any discrepancy with information in any article.
Page Last Updated: Thursday, 18-Mar-2010 05:56:21 CDT
