Fam Pract Manag. 2013 May-June;20(3):43.
- Immunization administration during preventive visits
- "Incident to" charges for counseling
- Subsequent annual wellness visits
Immunization administration during preventive visits
I have received denials for office visits and preventive visits when I have billed an immunization as part of the same claim. What do I need to do to avoid getting denials for these claims?
In January, the Medicare National Correct Coding Initiative (NCCI) implemented an edit that bundles the evaluation and management (E/M) code with the immunization administration code unless a modifier is used. To be paid for both services, you will need to append modifier 25 to all E/M codes, including preventive visit codes, that are reported for the same patient on the same date of service as an immunization administration. Code 99211 is an exception; NCCI does not permit payment of 99211 with an immunization administration even if modifier 25 is used. For more information, see the FPM Getting Paid blog.
"Incident to" charges for counseling
Can I bill “incident to” charges and be paid for counseling services provided in my office by marriage and family therapists and licensed professional counselors?
A First, let's consider your question with respect to Medicare. Two facts suggest that what you propose might not be possible. One is that marriage counseling and pastoral counseling are not covered by Medicare. The other is that licensed marriage and family therapists and licensed professional counselors are categories of nonphysician providers that are not currently recognized by Medicare, a status that means they cannot bill Medicare directly for their services. However, because Medicare does not have explicit requirements regarding the qualifications of auxiliary personnel who may provide “incident to” services, it is possible that some services of marriage and family therapists and licensed professional counselors could be reported “incident to” if they met the requirements and were not otherwise non-covered services.
Section 60 of chapter 15 of the Medicare Benefit Policy Manual states that “auxiliary personnel” means “any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician.” Typically, auxiliary personnel are considered to be clinical staff such as nurses and technicians. Other Medicare-recognized nonphysician providers, such as nurse practitioners, physician assistants, and clinical nurse specialists, may also have their services covered “incident to.”
In general, “incident to” services and supplies must be:
An integral, although incidental, part of the physician's professional service;
Commonly rendered without charge or included in the physician's bill;
Of a type that are commonly furnished in physician offices or clinics;
Furnished by the physician or by auxiliary personnel under the physician's direct supervision.
You may want to confer with your local Medicare administrative contractor before submitting a claim for the “incident to” services you've described.
As for commercial insurers, you should check with each carrier to confirm your understanding of their policies. Some may allow “incident to” billing for such therapists.
Subsequent annual wellness visits
What code describes the third and fourth subsequent Medicare annual wellness visits?
Code G0439, “annual wellness visit, including a personalized prevention plan of service, subsequent visit,” should be used after the initial visit.
Editor's note: Some payers may not agree with the advice given. Refer to current coding manuals and payer policies.
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Send questions and comments to firstname.lastname@example.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
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