If your patient is 19 years or older and requires counseling, continue to bill 99401– 99404 for counseling, with 90471 for immunization and 90649 or 90650 for the vaccine. Keep in mind: Whether you report 90460 or the 9940X codes, you are required to document the content of the counseling. Codes 9940X also require documentation of the duration of counseling.
INFLUENZA VACCINE
New codes have been established for the flu vaccine, but you won’t be using them: They are intended to address future pandemic strains of influenza. This year’s vaccine contains the H1N1 strain, but is coded as the normal seasonal flu vaccine, based on the type given:
90656 (preservative-free)
90658 (split virus)
90660 (intranasal)
90662 (enhanced vaccine for patients older than 65 years).
Changes to Medicare billing
Some of the coding and billing changes this year that have an impact on ObGyn practice come from the Centers of Medicare and Medicaid Services (CMS) and the Affordable Care Act.
TIMELY FILING
The Affordable Care Act calls for a reduction in the maximum time period for submission of Medicare fee-for-service claims. Before January 1, a provider had 15 to 27 months to submit first-time claims to Medicare. Now, these claims must be filed within a calendar year of the date of service. Exceptions can be made for retroactive entitlement or in situations in which there is a secondary payer.
PAYMENTS TO CERTIFIED NURSE MIDWIVES
Next, more good news—if you employ a certified nurse midwife (CNM) in your practice. Before January 1, Medicare reimbursed direct billing from a CNM at only 65% of the Medicare Physician Fee Schedule. Now, a CNM is paid the same as a physician when she (he) bills under her own number.
In the past, some practices billed for the services of a CNM under “incident to” rules, to capture the physician payment—but this also meant that the CNM could not see a new patient. Under the change I’m describing, all CNMs can bill Medicare directly; see new patients; and be paid the same as the physician is paid. In addition, CNMs are no longer required to be supervised by a physician when they perform diagnostic tests that fall under the scope of their practice.
ANNUAL WELLNESS VISIT
The Affordable Care Act extended preventive coverage to Medicare beneficiaries in the form of an annual wellness visit. The two new codes here have been valued based on a level 4-problem new and established E/M service:
G0438 Annual wellness visit, including personalized prevention plan services, first visit
G0439 Annual wellness visit, including personalized prevention plan services, subsequent visit
Payment for the initial visit is made only beginning the second year the patient is eligible for Medicare Part B—during the first year of coverage, only the Initial Preventive Physical Examination (IPPE) (the “Welcome to Medicare”) exam will be covered.
CMS has stated that only one physician will be paid for the initial visit; when the patient returns to the same or a new physician in the third year, only a subsequent visit will be paid. It is, therefore, important that this information be conveyed to any new physician who sees the patient.
The annual codes can be billed in addition to any other preventive service, such as G0101 or Q0091; no modifier is needed for this combination. Medicare has waived both the copayment and the deductible for the annual wellness visit, as well as all Medicare-covered preventive services that have been recommended with a grade of “A” (“strongly recommends”) or “B” (“recommends”) by the US Preventive Services Task Force.
The annual wellness visit requires seven elements at a minimum (i.e., you may document and perform more elements than this, but not fewer):
- Establish or update the patient’s medical and family history
- List her current medical providers and suppliers and all prescribed medications
- Record measurements of height, weight, body mass index (initial visit only), blood pressure, and other routine measurements
- Detect any cognitive impairment
- Establish or update a screening schedule for the next 5 to 10 years, including screenings appropriate for the general population, and any additional screenings that may be appropriate because of her particular risk factors
- Review the patient’s 1) potential (i.e., risk factors) for depression, based on use of an appropriate screening instrument, and 2) functional ability and level of safety based on direct observation or screening questions
- Furnish 1) personalized health advice and 2) refer her appropriately to health education or preventive services.
CMS has also indicated that, although they will pay for a problem E/M service and the annual wellness visit on the same date of service with a modifier -25 added to the E/M service, they expect this type of billing to be rare—because of the nature of the wellness visit, which is time-intensive. They also expect that, given these requirements, the patient will not be billed additionally for a noncovered preventive service.