PREVENTIVE MEDICINE SERVICE PROVIDED AT THE TIME OF COVERED SCREENING SERVICE
A preventive medicine exam includes a comprehensive age and gender appropriate history, examination, counseling/anticipatory guidance/risk-factor reduction interventions, and the ordering of appropriate immunization(s) and laboratory/diagnostic procedures. Sometimes these other elements are performed during the same visit as the Medicare covered services, particularly G0101 and Q0091. The following pie chart illustrates this circumstance.
Medicare will reimburse for the shaded parts of the pie (the collection of the Pap smear and the pelvic exam). The remaining portions of the preventive service are billed to the patient. The amount paid by Medicare is subtracted from the physician’s usual fee for a preventive service. The remaining amount is the patient’s fee. This is referred to as a “carve out,” meaning that Medicare’s covered portion of the preventive service is carved out of the total preventive service. The amount reimbursed by Medicare and the amount reimbursed by the patient will equal the physician’s usual fee.
Example : The “carve out” method for reporting the screening pelvic examination (G0101) with other preventive medicine care:
| Bill to: | CPT/HCPCS Code(s) | ICD-9 Codes | Charge |
| Medicare | G0101-GA | V72.31 or V15.89 | $34.60 |
| Patient | 99397-GY | V72.31 | $65.40 |
| Total amount billed | $100.00 | ||
The physician’s usual charge for the preventive visit (99397) is $100. The total billed to the patient and to Medicare equals the physician’s usual charge for the preventive service.
The GA modifier indicates that an ABN has been signed. Modifier GY is reported for a service that is not a Medicare covered benefit. The service is being reported to Medicare to receive a denial. The patient is responsible for the preventive service less the Medicare carve out amount.
Example 2: Preventive visit reported with screening pelvic examination (G0101) and collection of a screening Pap smear specimen (Q0091):
| Bill to: | CPT/HCPCS Code(s) | ICD-9 Codes | Charge |
| Medicare | G0101-GA | V72.31 or V15.89 | $34.60 |
| Q0091-GA | V72.31 or V15.89 | $40.00 | |
| Patient | 99397-GY | V72.31 | $25.40 |
| Total amount billed | $100.00 | ||
The physician’s usual charge for the preventive visit (99397) is $100. The total billed to the patient and to Medicare equal the physician’s usual charge.
The GA modifier indicates that an ABN has been signed. Modifier GY is reported for a service that is not a Medicare covered benefit. The service is being reported to Medicare to receive a denial. The patient is responsible for the preventive service less the Medicare carve out amount.
Once Medicare has processed the claim, the patient is billed for her portion of G0101 and Q0091. However, the patient can be billed at the time of service for the portion not covered by Medicare.