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February 2011 Client Newsletter

Medicare – New opportunities to treat patients

As you know, each year Medicare patients must meet their annual deductible which results in a significant cash flow slow down for many providers.

An interesting way to let them meet the deductible elsewhere is for you to use the new Medicare Wellness codes.

Medicare implemented a new Annual Wellness Visit (AWV) service which does NOT require a deductible or co-insurance for the patient.
· The current Initial Preventive Physical Exam (IPPE) (CPT Code G0402), which is available within the first 6 months of Medicare eligibility, has a 2011 Allowed Amount of $158.32.
· The new Annual Wellness Visit codes have Allowed Amounts for 2011: G0438 (Initial) = $173.22, and G0439 (Subsequent years) = $115.95.

Another preventive service that will not have a deductible or co-insurance is Counseling to Prevent Tobacco Use (includes counseling to stop smoking) and is are payable in addition to a regular office visit as long as there are 2 separate services (usually separate diagnosis codes):
- G0436 pays $14.89 for 3-10 minutes of counseling, and
- G0437 pays $30.08 for more than 10 minutes of counseling).

CMS allows 2 separate attempts and up to 4 visits each attempt per year. It also does NOT require a deductible or co-insurance for the patient and can be billed in addition to whatever office visit or procedure codes are billed.

New Medicare covered services

CMS has added the following requested services to the list of Medicare telehealth services for CY 2011:

• Individual and group KDE services:
HCPCS code G0420 (Face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour), Allowed Amount $117.28; and
HCPCS code G0421 (Face-to-face educational services related to the care of chronic kidney disease; group, per session, per one hour) Allowed Amount $27.79.

• Individual and group DSMT services (with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training):
HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) Allowed Amount $58.58; and
HCPCS code G0109 (Diabetes outpatient self-management training services, group session (2 or more) per 30 minutes) Allowed Amount $20.21.

• Group MNT and HBAI services, Current Procedural Terminology (CPT) codes:
- 97804 (Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes) Allowed Amount $14.86;
- 96153 (Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients) Allowed Amount $5.02, and
- 96154 (Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)) Allowed Amount $19.95;

Podiatrists and Nursing home visits

Effective 1/1/10, a Podiatrist can use 99304-99306 for the initial encounter. The 99304 pays about $50 more than the 99307 if the patient qualifies for the 99304.

Medicare 2011 ePRESCRIPTION (eRx) & PQRI

We have reviewed the 2011 CMS eRx requirements – the same code will be used in 2011. However, to avoid a 1% decrease in reimbursement in 2012, you must have at least 10 eRx’s in the first 6 months of 2011.

If you plan to do PQRI in 2011, be sure to check with Rich for 2011 PQRI requirements. They can change each year, and the current year’s measures and codes MUST be used in order to get paid.

Just a reminder that CMB will assist you with selection at no cost. The time to negotiate fees, including future options that you may or may not want, is before signing the purchase agreement.

Medicare prepayment review for 99204 & 99205

Highmark Medicare has announced that they will be performing prepayment reviews for all 99204 & 99205 charges. See the attached article from Highmark if you currently bill these codes.


ABN requirements include:
· A minimum of two copies, including the original, must be made so the beneficiary and health care provider each have one. The beneficiary should be given a copy of the signed and dated ABN immediately and the health care provider should retain the original copy with the beneficiary’s records.
· The ABN must not exceed one page in length; however, attachments are permitted for listing additional items and services. If an attachment sheet is used, a notation such as “See Attached Page” must be inserted in the Items/Services area of the ABN. Attached pages must include the following:
- Beneficiary’s name;
- Identification number (optional);
- Date of issuance;
- Table listing the additional items/services, the reasons Medicare may not pay, and the estimated costs; and
- A space below the table in which the beneficiary inserts his/her initials to acknowledge receipt of the attachment page.
· A visually high-contrast combination of dark ink on a pale background must be used.
· Some customization of the ABN is permitted.


If after completing and signing the ABN the beneficiary changes his/her mind, the health care provider should present the previously completed ABN to the beneficiary and request that he/she annotate the original ABN. The annotation must include a clear indication of his/her new option selection along with his/her signature and date of annotation. In situations where the health care provider is unable to present the ABN to the beneficiary in person, the health care provider may annotate the form to reflect the beneficiary’s new choice and immediately forward a copy of the annotated notice to the beneficiary to sign, date,and return.
Note: In both situations, a copy of the annotated ABN must be provided to the beneficiary as soon as possible.

If the beneficiary refuses to choose an option and/or refuses to sign the ABN, the health care provider should annotate the original copy of the ABN indicating the refusal to sign and may list witness(es) to the refusal on the notice, although this is not required. If a beneficiary refuses to sign a properly delivered ABN, the health care provider should consider not furnishing the item/service, unless the consequences (health and safety of the beneficiary, or civil liability in case of harm) are such that this is not an option.


An ABN is not needed every time for an extended course of treatment. A single ABN covering an extended course of treatment is acceptable, if the ABN identifies all items/services and duration of the period of treatment for which the health care provider believes Medicare will not pay. If the health care provider believes Medicare will deny additional services furnished during the course of treatment, a separate ABN is needed.
A single ABN for an extended course of treatment is valid for one year.
2011 Client Newsletter Archive