CMS Preventive Services for Medicare Patients refers to the Centers for Medicare & Medicaid Services (CMS) programs that provide preventive healthcare services to Medicare beneficiaries. These services are designed to detect and address health issues early, helping seniors maintain their well-being and potentially reducing healthcare costs in the long run. Preventive services covered by Medicare may include vaccinations, screenings, annual wellness visits, and counseling on various health-related topics. These services are essential for promoting the health and longevity of Medicare patients while preventing more serious and costly medical conditions. The webinar is designed to provide information and guidance to healthcare providers and professionals on preventive services covered by Medicare for their patients. These services are aimed at helping Medicare patients maintain and improve their health by identifying and preventing illnesses or conditions. The webinar likely covers topics such as eligibility, coding, billing, and updates on preventive services guidelines for Medicare beneficiaries. It is a resource to keep healthcare providers updated on Medicare's preventive care offerings. Register, https://conferencepanel.com/conference/cms-preventive-services-medicare-patients

1. Preventive Services
PRESENTED BY
JAN RASMUSSEN, PCS, ACS-OB, ACS-GI
PROFESSIONAL CODING SOLUTIONS

2. 2
PREVENTIVE
OFFICE
VISITS
99381-99397

3. Diagnosis Coding
• Z00.00 Encounter for general adult medical
examination without abnormal findings
• Z00.01 Encounter for general adult medical
examination with abnormal findings
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4. 4
Prevent & Covered Visit Same Day
• IOM 100-04 C12 30.6.2
When a physician furnishes a Medicare beneficiary a covered
visit, at the same place and on the same occasion as a
preventive medicine service (CPT codes 99385-99387 or
99395-99397), consider the covered visit to be provided in lieu
of a part of the preventive medicine service of equal value to
the visit.
− The physician may charge the beneficiary, the amount by
which the physician’s current established charge for the
preventive medicine service exceeds his/her current
established charge for the covered visit.

5. 5
Breast and Pelvic Exam (G0101)
• Payable every 2 years for Medicare patient.
• If considered high risk payable annually.
• High risk identified with Z91.89 as primary
diagnosis
✓ sexual activity under 16 yrs old (Z72.51, Z72.52,
Z72.53)
✓ 5+ sexual partners (Z72.51, Z72.52, Z72.53)
✓ hx of sexually transmitted dx (Z87.42)
✓ absence of 3 negative paps (R87.619)
✓ hx of HIV (Z21 or B20)
✓ no pap smears for 7 years (no ICD-10)
✓ prenatal exposure to DES (P04.89)

6. 6
G0101…
• Reimbursement less than 99212
• Deductible does not apply.
• Can be billed with another E/M “sick visit”.
• Requires carve-out when billed with preventive med code
(99385-99387or 99395-99397).
• Routine:
− Z01.411, Z01.419
• Should only be used when the provider performs a full gynecological examination.
• Z12.4 for special screening, malignant neoplasm cervix.
− Patients without uterus or cervix use:
• Z12.72 screening for malignancy of vagina
− Hysterectomy for non malignant condition
• Z12.79 screening for malignant neoplasm of other genitourinary organs
• No longer screening
− Follow up for completed treatment for malignant neoplasm (Z08) with
Z90.710/Z90.711 acquired absence of cervix/uterus or just uterus and
PH Z85,41, Z85.42, Z85.43 hysterectomy for malignancy

7. 7
Q0091
• Q0091 billed separately for collection of pap
smear with same diagnosis as G0101
• Note MUST state pap smear obtained!
• Screening pap smears also payable every 2 years.
• Q0091 and G0101 may not always coincide for
frequency (i.e. 2002 Q0091 and 2003 G0101).
• Requires waiver if performed more frequently.

8. 8
S Codes
• Well Service Codes – Non Medicare
− S0610 Annual gynecological examination, new
patient
− S0612 Annual gynecological examination,
established patient
− S0622 Physical exam for college, new or
established patient

9. 9
RISK AREAS – PREVENT MED
• 99204/05 or 99214/15 instead of prevent medicine
code.
• Medicare considers that fraudulent billing
• Combined prevent medicine and “f/u chronic
problems”.
• “Here for annual evaluation of HTN, hypothyroidism and
hyperlipidemia and preventive medicine services”.
• No clear documentation of separate work only renewed meds
• “Sick” services being provided for nothing.
• Never reporting prevent med services, G0101, Q0091.
• Incomplete documentation to support “sick” visit.
• Complaints not addressed in A&P

10. 10
IPPE
• Effective 1/1/05
• Should be called Welcome to Medicare
Evaluation rather than exam
− G0402 - Initial preventive physical
examination
− 1 initial preventive exam within first 12
months after the effective date of
beneficiary's first Part B coverage period

11. Annual Wellness Visit (AWV)
• Preventive wellness visit not a “routine physical
check up as patient’s are accustomed to”
− AWV does not replace a complete head-to-toe
physical exam.
− A yearly physical CPT codes: 99385-99387,
99395-99397) is never a covered service
• G0438 initial
• G0439 subsequent
• No deductible or coinsurance
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12. Hepatitis C Screening G0472
• High risk individuals
− Current or past history of illicit injection drug
use; and persons who have a history of
receiving a blood transfusion prior to 1992.
− Covered annually only for persons who have
continued illicit injection drug use since the
prior negative screening test.
• Non high risk
− Born from 1945 through 1965.
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13. 99406/99407 Smoking Cessation
• 99406 Smoking and tobacco use cessation
counseling visit; intermediate, greater than
3 minutes up to 10 minutes
− Reimbursement approximately $15.00
• 99407 Smoking and tobacco use cessation
counseling visit; intensive, greater than 10
minutes
− Reimbursement approximately $28.00
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14. G0442/G0443 Alcohol Misuse
• G0442 Annual alcohol misuse screening, 15
minutes
− ICD-10 Z13.89 unless alcohol misuse identified
− Only once in 12 month period
• G0443 Brief face-to-face behavioral counseling
for alcohol misuse, 15 minutes
− ICD-10: F10.xx codes
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15. G0444 Depression Screening
• G0444 Annual depression screening, 15 minutes
− Cannot be paid performed more than one time in a 12-month
period
− Not for patients with confirmed depression diagnosis
• ACA indicates “Do not provide long-term pain
management without a psychosocial screening or
assessment”.
− High probability that any person with a chronic pain syndrome
has a concomitant psychological disorder, most notably
depression and/or anxiety.
• Diagnosis (unless depression detected): Z13.89
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16. G0445 STI Prevention
• G0445 Semiannual high intensity behavioral
counseling to prevent STIs, individual, face-to-
face, includes education skills training & guidance
on how to change sexual behavior
− Provided by a Medicare eligible primary care provider
in a primary care setting
• Covers up to two individual 20- to 30-minute,
face-to-face counseling sessions annually for:
− All sexually active adolescents and for adults at
increased risk for STIs
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17. Counseling for Obesity
• G0447 Face-to-face behavioral counseling
for obesity, 15 minutes
− For prevention or early detection of illness or
disability.
− Obesity defined as BMI ≥ 30 kg/m2,
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18. Immunizations
• Pneumococcal, influenza, COVID 19 and
hepatitis B vaccine and their administration
− Hepatitis B must be considered high risk
− Shingles vaccination under Part D
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19. Tracking Eligibility
• Through CMS HIPAA Eligibility Transaction
System (HETS) either directly or through your
eligibility services vendor
• Through your MAC provider call center Interactive
Voice Response (IVR) unit,
OR
• Through your MAC provider web portal.
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