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Medical Coding News Archives

Medicare Covers More Prevention in Primary Care Setting

 
February 16, 2012:

Wendy Gabbert, CPC, CPC-H, Clinical/Technical Editor

Several new screening and counseling services provided in the primary care setting are now covered by Medicare, thanks to a focus on preventive services as a way to reduce health care costs.

A preventive service is covered by Medicare if it is:

  • Reasonable and necessary for the prevention or early detection of illness or disability
  • Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF)
  • Appropriate for individuals entitled to benefits under Part A or enrolled under Part B of the Medicare program

Recently added preventive services include:

  • Obesity screening and intensive behavioral counseling
  • Screening for sexually transmitted Infections (STIs), and high-intensity behavioral counseling to prevent STIs
  • Screening for depression in adults
  • Screening and behavioral counseling interventions in primary care to reduce alcohol misuse
  • Intensive behavioral therapy for cardiovascular disease

Primary care providers treat various conditions and usually have an ongoing relationship with the patient. Providers who can submit claims for preventive services in the primary care setting must be enrolled in one of the following specialties:

01—General practice
08—Family practice
11—Internal medicine
16—Obstetrics/gynecology
37—Pediatric medicine
38—Geriatric medicine
50—Nurse practitioner
89—Certified clinical nurse specialist
97—Physician assistant

With one of the following place-of-service codes:

11—Physician’s office
22—Outpatient hospital
49—Independent clinic
71—State or local public health clinic

Emergency departments, inpatient hospitals, ambulatory surgery centers (ASCs), independent diagnostic testing facilities, inpatient rehabilitation facilities, skilled nursing facilities (SNFs), and hospices are not considered primary care settings.

Medicare will deny claims for such services if they are submitted by physicians of other specialties or performed in another place of service.

Also keep in mind that most preventive services have specific frequency and diagnostic limitations with which the provider and office staff should become familiar.

 

 

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