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Billing
For Medically Necessary Visit On Same Occasion As
Preventive Medicine Service.--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 99381-99397),
consider the covered visit to be provided in lieu of a
part of the preventive medicine service of equal value
to the visit. A preventive medicine service (CPT codes
99381-99397) is a non-covered service. The physician
may charge the beneficiary, as a charge for the
noncovered remainder of the service, 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. Pay
for the covered visit on the basis of the lesser of
the fee schedule amount or the physician's actual
charge for the visit. The physician is not required to
give the beneficiary written advance notice of
noncoverage of the part of the visit that constitutes
a routine preventive visit. However, the physician is
responsible for notifying the patient in advance of
his/her liability for the charges for services that
are not medically necessary to treat the illness or
injury.
There could be covered and non-covered procedures
performed during this encounter (e.g., screening
x-ray, EKG, lab tests.). These are considered
individually. Those procedures which are for screening
for asymptomatic conditions are considered noncovered
and, therefore, no payment is made. Those procedures
ordered to diagnose or monitor a symptom, medical
condition, or treatment are evaluated for medical
necessity and, if covered, are paid.
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