Rank: New Member
Joined: 12/23/2013(UTC)
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Good Morning,
We are having issues with billing initial exams and re-exams for our medicare patients.
When billing a new patient exam 9920_ and re-exam 9921_ we get the response that "it is not covered because it is routine/preventative exam...."
To take it one step further there are several patients that Dr. Madden will do a perio exam on and we bill the dental for this routine exam. Lets say she finds that they have candidia, or thrush, or lichen planus, etc., we prescribe medications and we have the patient come back for a re-exam I bill using the 9921_ and get the same response.
After much research, I found that for tobacco cessation there is a 'special' exam code to use. Is there a different or 'special' code that we should be using for these follow-ups? Should these be covered benefits? We just can't imagine that doctors that bill for new patient and re-exams aren't' getting paid for these from Medicare. Our neighbors are dermatologist and they have no problems.
Any advise or help would be useful at this point
Thank you!
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Rank: Administration
Joined: 11/21/2012(UTC)
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Hi talk2us@finetunegumes.com! Great questions. Yes, Medicare Part B does state that they do not cover “routine dental care” such as crowns, bridges, implants, cleanings, oral exams, etc. Those services can be billed to the patient’s dental insurance policy if they have one available. There are certain diagnosis codes that may establish medical necessity for some of these services, for example accident cases, lesions/malignant neoplasms, etc….. Candidia, Thursh, and lichen planus are likely diagnoses that are considered not medically necessary for those procedures. Now, on the tobacco cessation side: Here is a link to your Medicare Part B jurisdiction’s (noridian) information on preventative service (tobacco cessation counseling included on list as covered service): https://www.noridianmedicare.com/partb/train/education_center/preventive_services.htmlHere are screenshots attached to this post of the high points from the info with guidelines, codes, etc! courtneydsnow attached the following image(s):
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Rank: New Member
Joined: 12/23/2013(UTC)
Posts: 8
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Thank you for that wealth of information.
But what about if the condition is being caused by a medication(s) they are on?
Dianna
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Rank: Administration
Joined: 11/21/2012(UTC)
Posts: 1,611
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Hi talk2us@finetunegums.com! Great question. I could not location a medical policy for Medicare that directly addresses treatment for adverse effects of drugs, but that situation could definitely change things! Diagnosis code 995.20 stands for unspecified adverse effect of unspecified drug, medicinal and biological substance, and could be considered medically necessary but also may require medical review.
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